Increasingly complex issues such as loneliness, caregiving challenges for relatives, homelessness, violence, hoarding, animal hoarding, and a lack of self-help resources in simple medical and social crises demand new approaches. Due to limited 24/7 availability and the partial specialization of social services, affected individuals are often directed primarily to the medical system due to its low-threshold and fast access for those seeking help.

This system is both professionally and quantitatively overwhelmed. So-called “frequent flyers” among patients are the result of this misallocation. The situation could be sustainably improved through Social Work services such as preventive counseling, outreach and follow-up care, and crisis intervention. Furthermore, transdisciplinary networking and integration of support services are needed to guide these patients in acquiring basic self-help skills. The goal is to identify an adequate point of care that truly meets actual needs, to empower affected individuals within their social environment, and to sustainably relieve hospitals.

As part of the pilot implementation of the telephone health advisory system Teweb, reliable referral options to social services are being sought in terms of time, location, and content. These services will (and can) not always be available comprehensively, around the clock, or with specialized focus. Therefore, the questions arise: What response options are possible through community-based outreach social work? How can training programs and institutional connections be designed? In this context, Community Response Teams from the US serve as a conceptual model.