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The position involves working closely with patients to ensure their needs are met from admission through discharge. The role requires conducting thorough assessments upon patient admission to understand their individual circumstances and needs. This includes gathering relevant information that will inform the care plan and ensure that all necessary services are in place before the patient is discharged. The professional will also play a crucial role in discharge planning, which involves making referrals to appropriate services and ensuring that patients have access to the resources they need after leaving the facility. Post-discharge follow-up is a critical aspect of this role, as it ensures that patients continue to receive the necessary support and services. This may involve contacting patients to check on their well-being and coordinating with other service providers to facilitate ongoing care. Additionally, the position requires assisting in arranging transportation for patients to other facilities when necessary, ensuring that they can access the care they need without barriers. Collaboration with residents and their families is also an important part of the job. The professional will involve them in planning social service programs whenever possible, fostering a sense of community and support. Maintaining a quality working relationship with the medical profession and other health-related facilities and organizations is essential to ensure a seamless continuum of care for patients. This role is pivotal in bridging the gap between healthcare services and the patients' social needs, ultimately contributing to improved health outcomes and patient satisfaction.