Social Services Designee

Social Services Designee

The Social Services Designee interacts with the residents, families, visitors, other facility staff, and community agencies during the admission and discharge process. They are responsible to market the services we provide and establish relationships with all referral sources. They clarify a range of legal documents for residents and families as well. As a member of the interdisciplinary care planning team, the Social Service position identifies the psychosocial strengths and needs of each resident, assists in developing an individualized plan of care, and provides medically-related social services to help the resident attain or maintain the highest level of functioning possible.

• Accepts admission referrals and obtains the required information.
• Gives tours of facility to prospective residents/families. Distribute information about the Rehabilitation Center.
• Makes referrals as needed for pre‑admission screening and pre‑admission physician visits.
• Obtains pre‑admission screening approvals from appropriate counties.
• Assists residents/responsible parties with completing required admission paperwork, forwards information to Corporate Office on a timely basis.
• Maintains resident records by entering admission summary, quarterly notes, interaction with resident, etc. into medical record per facility policy.
• Assists residents/responsible parties with applications for financial assistance from appropriate government agencies as necessary.
• Develops, maintains and documents ongoing discharge plans for each resident.
• Completes the Social Services discharge summary in coordination with the interdisciplinary team.
• Make referrals to appropriate home health agencies as requested by resident/responsible parties.
• Assists with obtaining needed home health equipment.
• Maintains knowledge of community resources and utilizes these appropriately at time of discharge planning.

• Assists resident/families with adjustment to facility placement.
• Accepts placement referrals from community agencies or individuals.
• Acts as liaison between residents/families and the facility staff for concerns, questions, and in particular, personal needs.
• Visits 1:1 with residents to assess psychosocial needs and to provide reassurance and support.
• Informs residents/families of the right to make advanced directives and decisions about treatment as well as other rights.
• Supportive to residents/families in the grieving process.
• Informs residents/responsible parties of change in roommate, if necessary.
• Communicates with residents/responsible parties about room changes and coordinates changes with facility staff.
• Encourages family involvement and support.
• Provides support, encouragement and information to residents that have psychosocial needs or problems.
• Communicates to appropriate facility staff the psychosocial needs and problems of each resident.
• Makes referrals to community individuals or agencies to meet psychosocial needs.

• Completes a Patient Health Questionnaire (PHQ‑9) and Brief Interview for Mental Status (BIMS) per facility policy.
• Completes a social history and assessment of each resident upon admission.
• Documents follow-up at initial conference time and quarterly thereafter.
• Completes assigned sections of MDS, CAA’s and summaries.
• Participates in development of the care plan coordinate and facilitate Patient Care Conferences.
• Identify, update and implement care plan approaches assigned to Social Services closely assessing psychosocial and behavioral needs.

• Is courteous and cooperative with residents, families, visitors, supervisors and co‑workers.
• Follows dress code, wears name tag, and limits personal phone calls.
• Is courteous and cooperative with residents, families, visitors, supervisors and co‑workers.

• Promotes a…