Social Services Assistant

The Social Service Assistant will provide initial contact with families into the patients stay to inquire about any questions/concerns and also inform them of upcoming surveys. The Social Service Assistant is also responsible for coordinating the safe and effective discharge of patients from the nursing home. This role ensures that patients and their families are prepared for the transition from the facility to their next setting of care, whether that be home, another facility, or rehabilitation services. The Social Service Assistant works closely with interdisciplinary teams, including nurses, social workers, and therapy staff, to develop and implement individualized discharge plans. The Social Service Assistant will also be responsible for discharge follow up calls after discharge to ensure patient is doing well after transition of care.

Key Responsibilities:

1. Discharge Planning:

• Collaborate with the healthcare team to assess patients' needs and develop

comprehensive discharge plans.

• Facilitate communication between patients, families, and external care providers to ensure

smooth transitions.

• Educate patients and families on post-discharge care requirements, including medication

management, follow-up appointments, and community resources.

2. Coordination of Care:

• Liaise with home health services, durable medical equipment providers, and other

community resources to ensure patients have necessary support after discharge.

• Ensure all necessary documentation is completed for a smooth discharge process,

including the provision of discharge instructions and prescriptions.

3. Patient and Family Education:

• Provide clear and compassionate education to patients and families regarding the

discharge process and post-discharge care expectations.

• Address concerns and questions from patients and families to promote understanding and

comfort with the transition plan.

4. Follow-Up:

• Conduct post-discharge follow-ups as necessary to check on patient progress and address

any issues that may arise.

• Monitor patient outcomes to ensure the effectiveness of discharge plans and to make

improvements where necessary.

5. Compliance and Documentation:

• Ensure that discharge plans meet regulatory standards and comply with facility policies.
• Maintain accurate and detailed records of all discharge planning activities and interactions

with patients, families, and care providers.

6. Team Collaboration:

• Participate in interdisciplinary team meetings to discuss patient progress and discharge

readiness.

• Work closely with nursing staff, social services, and therapy departments to ensure the

discharge plan is holistic and meets the patient's physical, emotional, and social needs.

• Assist Social Services with Care Plans, primarily calling continuity care stay family

members to provide updates

7. NPS Champion

• Conduct follow up phone calls for admission, anniversary and discharges.
• Champion center Activated Insights process by educating team members about results

and process.

Qualifications:

• Associate's degree in nursing, Social Work, or healthcare related experience are preferred.
• Previous experience in discharge planning, care coordination, or case management in a

healthcare setting.

• Strong communication and interpersonal skills, with the ability to collaborate effectively with

patients, families, and healthcare professionals.

• Knowledge of community resources, home health services, and post-acute care options.
• Ability to manage multiple tasks and prioritize work in a fast-paced environment.
• Familiarity with healthcare regulations and discharge planning protocols.

Working Conditions:

• Full-time position.
• May involve occasional weekend or evening work, depending on patient needs.
• Requires regular interaction with patients, families, and healthcare staff.