Social Services Designee

The Social Worker is responsible for providing social work services to residents and their families within our Skilled Nursing Facility (SNF). The role involves assessing psychosocial needs, coordinating care, and advocating for residents to enhance their overall well‑being.

• Conduct comprehensive psychosocial assessments for residents and integrate findings into individualized care plans.
• Provide counseling and emotional support to residents and families, addressing adjustment to long‑term care, grief, and end‑of‑life concerns.
• Facilitate support groups and educational sessions as needed.
• Coordinate with nurses, therapists, physicians, and other health professionals to ensure holistic care.
• Advocate for residents’ needs within the care team.
• Develop and implement discharge plans for residents transitioning to other settings or home.
• Collaborate with post‑discharge service providers and community resources.
• Assist in advance care planning, including developing advance directives and discussing end‑of‑life preferences.
• Connect residents and families with community resources such as financial assistance, legal aid, and transportation services.
• Communicate regularly with families to provide updates, address concerns, and involve them in care planning.
• Conduct family meetings when necessary.
• Provide crisis intervention and support during emergencies or sudden health declines.
• Maintain accurate and up-to-date documentation of assessments, interventions, and interactions.
• Ensure compliance with regulatory standards and facility policies.
• Advocate for residents’ rights, dignity, and quality of life, and report concerns related to abuse or neglect.

• Empathy and sensitivity in working with diverse populations, especially elderly individuals and families.
• Effective communication and interpersonal skills.
• Knowledge of relevant laws, regulations, and ethical standards in social work.
• Ability to collaborate with interdisciplinary teams and community agencies.