Transitional Care Social Worker

St. Ann's Community•Rochester, NY

1d•$58,000 - $66,000

About The Position

Provides social work services to patients and families in a rehabilitation and Transitional Care Center from admission through discharge. The role assesses psychosocial needs, supports adjustment to illness and changes in function, and coordinates discharge planning with patients, their chosen supports, and the interdisciplinary team. It promotes patient choice, continuity of care, and access to services needed for the next level of care. The Social Worker completes psychosocial assessments, participates in care planning and rehabilitation rounds, provides support and education, advocates for patient rights, and coordinates individualized transitions of care. The role also maintains documentation, completes assigned MDS interviews and assessments, coordinates with community agencies and other disciplines, and provides rotating weekend coverage and assigned evening or weekend on-call coverage. Other related duties are assigned by the Social Work Manager.

Requirements

Bachelor’s degree in social work (BSW), gerontology, or equivalent, with two years of related experience and/or training, or an equivalent combination of education and experience.
Ability to communicate clearly with patients, families, and interdisciplinary team members; lead care planning discussions; and respond professionally to concerns.

Nice To Haves

New York State licensure is preferred.
Social work experience in short-term rehabilitation, transitional care, or a skilled nursing facility is preferred, particularly discharge planning and coordination of community services.
PointClickCare experience is preferred.

Responsibilities

Welcome patients and families, explain the social work role and rehabilitation process, assist with adjustment, and address questions or refer concerns appropriately.
Complete social histories and psychosocial assessments covering living arrangements, function, supports, coping, cultural preferences, cognition, mood, and community resources.
Identify patient goals, discharge preferences, caregiver availability, and potential discharge barriers; verify contacts and decision-making representatives through available documentation.
Participate in interdisciplinary care planning and rehabilitation rounds, updating psychosocial goals and interventions as needs change.
Coordinate and participate in patient and family meetings about progress, care needs, discharge options, and concerns; encourage patient involvement and participation by supports chosen by the patient.
Provide supportive counseling, education, and referrals within the role and training for adjustment, grief, anxiety, caregiver stress, and changes in health or independence.
Communicate psychosocial, mood, cognitive, behavioral, and safety concerns to appropriate team members and seek consultation when needs exceed the role’s scope.
Assist with advance care planning conversations and access to advance directive information; refer specialized questions to appropriate professionals.
Advocate for patient rights, privacy, dignity, and informed choices; help resolve concerns and connect patients and families with grievance or support resources.
Coordinate individualized discharge planning based on patient goals, function, home environment, supports, and interdisciplinary recommendations.
Assess and communicate discharge barriers, including caregiver support, housing, transportation, finances, service availability, and equipment needs; work with the team to identify options.
Collaborate with therapy and nursing on assistance needs, caregiver training, and equipment recommendations; confirm patient and caregiver understanding and ability to arrange support.
Coordinate referrals to home health agencies, community programs, and other providers; work with vendors on durable medical equipment and supplies and follow up on referral acceptance and anticipated start dates.
Assist with referrals and applications for assisted living, long-term care, or other settings when return to the prior living arrangement is infeasible or not preferred.
Coordinate transportation and communicate discharge arrangements to patients, appropriate supports, and receiving providers; collaborate on follow-up appointments, instructions, and continuity-of-care information.
Explain social and practical aspects of insurance coverage and discharge planning with reimbursement staff and the Business Office; assist with assigned notices and appeal procedures under facility policy and refer coverage or financial questions appropriately.
Escalate unresolved discharge risks, disagreements, and requests to leave against medical advice to the Social Work Manager and clinical team; document options, preferences, and referrals, including protective services when indicated.
Provide emotional support during transitions, complete assigned discharge documentation, and conduct post-discharge follow-up according to department procedures.
Maintain timely, accurate, and objective documentation in PointClickCare or the designated electronic health record.
Complete assigned MDS interviews, assessments, and related documentation within applicable timeframes and training requirements; communicate significant findings to the interdisciplinary team.
Prioritize a changing rehabilitation caseload and time-sensitive discharge needs, provide clear handoffs, and follow up on pending services, referrals, and concerns.
Collaborate with disciplines and community agencies to connect patients and families with benefit information and assistance with health-related forms, including Medicaid resources when appropriate.
Participate in quality improvement, required education, and departmental meetings; assist with staff or student orientation and patient or family education as assigned.
Provide rotating weekend social work coverage and assigned evening or weekend on-call coverage in accordance with department scheduling and facility policy.
Perform other related duties as assigned by the Social Work Manager.