Transitional Care Social Worker

St Anns Community•Rochester, NY

About The Position

Provides social work services to patients and families in the rehabilitation and Transitional Care Center setting from admission through discharge. Assesses psychosocial needs, supports adjustment to illness and changes in function, and coordinates discharge planning with the patient, chosen supports, and interdisciplinary team. Promotes patient choice, continuity of care, and access to services needed for the next level of care. The role includes admission and psychosocial assessment, care planning and patient and family support, discharge planning and transitions of care, documentation, and department coordination. The social worker maintains timely, accurate documentation in PointClickCare or the designated electronic health record, completes assigned MDS interviews and related documentation, and manages a changing rehabilitation caseload and time-sensitive discharge needs. The position provides rotating weekend coverage and assigned evening or weekend on-call coverage in accordance with department scheduling and facility policy. This is a full-time position of 37.5 hours per week. The listed salary range is $58,000–$66,000 gross per year.

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

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

Responsibilities

Welcome patients and families, explain the social work role and short-term rehabilitation process, and assist with adjustment to the unit.
Review assigned admission information, patient rights, communication preferences, and facility procedures; address questions and refer concerns appropriately.
Complete social histories and psychosocial assessments covering living arrangements, baseline function, support systems, coping skills, cultural preferences, cognition, mood, and community resources.
Identify patient goals, preferred discharge location, caregiver availability, and potential discharge barriers; verify appropriate contacts and decision-making representatives through available documentation.
Participate in interdisciplinary care planning and rehabilitation rounds, and update psychosocial goals and interventions as needs change.
Coordinate and participate in patient and family meetings about progress, care needs, discharge options, and unresolved concerns; encourage patient participation and involvement of supports chosen by the patient.
Provide supportive counseling, education, and referrals within the employee’s role and training for adjustment, grief, anxiety, caregiver stress, and changes in health or independence.
Communicate psychosocial concerns, mood or cognitive changes, behavioral needs, and safety concerns to appropriate team members; seek supervisory or clinical consultation when needed.
Assist with advance care planning conversations and access to advance directive information; refer clinical, legal, or specialized questions to appropriate professionals.
Advocate for patient rights, privacy, dignity, and informed choices, and connect patients and families with appropriate grievance or support resources.
Coordinate individualized discharge planning throughout each stay using patient goals, current function, home environment, available supports, and interdisciplinary recommendations.
Assess and communicate discharge barriers, including caregiver support, housing, transportation, finances, service availability, and equipment needs, and work with the team to identify options.
Collaborate with therapy and nursing on assistance needs, caregiver training, and recommended equipment; confirm patient and caregiver understanding and ability to arrange support.
Coordinate referrals to home health agencies, community programs, and other providers; work with the team and vendors on durable medical equipment and supplies; follow up on referral acceptance and anticipated start dates.
Assist with referrals and applications for assisted living, long-term care, or other settings when returning to the prior living arrangement is infeasible or not preferred.
Coordinate transportation and communicate discharge dates and 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 in coordination with reimbursement staff and the Business Office; assist with assigned notices and appeal procedures under facility policy and refer coverage or financial questions to appropriate staff.
Escalate unresolved discharge risks, disagreements, or requests to leave against medical advice to the Social Work Manager and clinical team; document options, patient preferences, and referrals, including protective services when indicated.
Provide emotional support during transitions, complete assigned discharge documentation, and perform post-discharge follow-up according to department procedures.
Maintain timely, accurate, and objective documentation in PointClickCare or the designated electronic health record, including assessments, interventions, care plans, family communication, referrals, and discharge arrangements.
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 unresolved concerns.
Collaborate with other 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.