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 ab...