JOB SUMMARY

• The Social Service Discharge Planner (SSDP) is responsible for performing assigned social work duties and responsibilities within the facility, with a main focus on discharge (d/c) planning as a part of resident care. The SSDP is responsible administratively to the facility to plan, develop, organize, oversee, and run the overall discharge operation of the Social Service Department in accordance with current Alden policies and procedures, Federal, State, and local standards, guidelines, and regulations, and as may be directed by the Administrator, to meet individual resident needs in coordination and conjunction with overall facility goals. The SSDP reports to the Administrator and accepts consultation/supervision from the Corporate Coordinator of the Social Services Program and the Director of Operations of Clinical Programs.

QUALIFICATIONS

• Have one year of experience working in the social service/case management realm of the healthcare field, including an emphasis on discharge planning.
• Current knowledge of Federal and State Long-Term Care (LTC) Social Service regulations and/or ability to understand and interpret.
• Demonstrate skills and ability in working with and understanding the needs of the residents, families, other staff members and personnel from community agencies.
• Must be able to read, write, and speak the English language in an understandable manner. The ability to produce concise, meaningful, clinical written reports, assessments, documentation, and care planning initiatives and articulate the social/psychological needs of the residents.
• Must possess the ability to make independent decisions when circumstances warrant such action that are in the best interest of the residents, staff, and families. Must possess the ability to deal tactfully with residents, family members, visitors, personnel, government agencies/personnel and the general public in a professional manor.
• Must possess leadership ability and a willingness to work harmoniously with other personnel.
• The ability to accept and utilize professional supervision, consultation, and in-service training/educational opportunities.
• Must demonstrate the ability to handle confidential data with professional discretion.
• Have experience and qualified marketing skills to effectively express the Alden’s Social Services Program to the community, other health professionals, outside professional organizations, senior services, government agencies, and any other provider or professional in the community.
• Must have the sincere desire to work with a variety of populations that require long-term or short-term care.
• Possess a knowledge and ability to apply that knowledge to deal effectively with this population.
• Possess the ability to guide and direct staff in therapeutic approaches effective with the dementia and behavioral population, as well as residents with mental health issues, on an- ongoing basis, if applicable.
• Possess the qualities of empathy, compassion, understanding, enthusiasm, and humor in order to effectively interact with residents, families, and staff.
• Willingness to be flexible regarding working hours in order to ensure quality of care.
• Understand and be able to manage emotional needs of yourself and your staff.

PHYSICAL REQUIREMENTS

• Must be able to move intermittently throughout the workday.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively with the residents, family members, personnel, and support agencies.
• Must be in good general health and demonstrate emotional stability.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to relate to and work with (physically/mentally) ill, disabled, elderly, emotionally upset and at times hostile people.
• Must be free of physical limitation so as to be able to participate in the physical crisis prevention (CPI) techniques as trained by a certified trainer.
• May be required to lift equipment, supplies, and occasionally move furniture.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including exposure to HIV, AIDS, and Hepatitis B virus.

Job Duties and Responsibilities

• Be available to welcome new admission residents, provide support and initiate a trusting/therapeutic relationship.
• Must be able to clearly assess and document residents’ identified feelings about LTC placement (short/long-term), emotional, mental, environmental changes or physical limitations verbalized by resident (or family), which includes any observed non- verbal communications.
• Become knowledgeable of each individual resident’s background, cultural, life history, disease, and medical care needs in detail to ensure an appropriate person- centered social service plan.
• Document interaction with and in-between resident and/or family in the assessment, care plan and/or social services notes in support of resident advocacy as required by the State standards of practice. It may be necessary to interview family, friends, community agency representatives and utilize clinical records in order to complete thorough documentation.
• Imitate, facilitate, and/or participate in the written discharge plan which states the resident’s specific need to be in the facility or if the resident is expected to be able to function in a more independent setting. The discharge plan should include consultation with other disciplines, the family and of course the resident. The plan of care will involve working with physician, OT/PT/ST, family, and resident to refer as needed to social, health and community agencies for the purpose of referral. These agencies include, but are not limited to: Home Health Agencies, Hospice, The Department of Mental Health and Developmental Disabilities, Department of Public Aid, Department of Rehabilitation Services, Veteran’s Administration, community mental health centers, sheltered workshops, hospital programs, shelters, social clubs, weekly hotels, etc. Document as required by policy; State regulations expect referral collaboration within 10 days of the date when resident expressed the desire to be feasibly discharged. Prepare a plan of care for discharge (i.e., “Care Plan”) with the Interdisciplinary Team (IDT) based on the Comprehensive Assessment for each resident. Contribute as an integral member of the IDT on a continual basis and at the Resident Care Plan Conferences.
• Provide good rapport through active listening with residents who express the need to talk and must be available to provide supportive counseling and behavioral intervention/programming as identified through oneself and/or community programming, at the discretion of the SSD. Must assist the resident to participate in individual and/or group programs and to utilize these programs to full advantage when offered in order to empower residents for better quality of life.
• SSDP must act as resident advocate, as well as a liaison between the resident and his/her family, the facility and community agencies.
• Maintain adequate record system for obtaining, recording, and filing of social service information. Participate in the development, maintenance, and implementation of the facility’s Quality Improvement Programs.
• Participate in the facility safety committee, as assigned.
• Perform other related duties as assigned.

Social Service Goals

• Participate in the achievement of facility and program goals through a team approach.
• Maintain a therapeutic person-centered social service program which constantly strives to enhance the quality of life and meets the needs of each resident.
• Maintain all Social Services Policies and Procedures and State and Federal regulations.

Assessments/Documentation

• Conduct, oversee, and complete initial and all on-going d/c assessments and MDS, CAAs and care planning initiatives, including but not limited to d/c planning, amongst others as it relates to individual social service needs.
• Entering an initial assessment note in the social service section of the chart within 48 – 72 hours of admission, as it relates to d/c, completing assigned sections of the MDS and CAAs, and completing assigned social service assessments to be completed within 14 days of admission, re-evaluation of the resident on a quarterly basis (sooner when a significant change/behavioral incident occurs/discharges to hospital), and a comprehensive re-evaluation annually.
• Assess, intervene, document and follow-up with all behavioral incidents, as necessary.
• Complete all required documentation.

Social Service Education

• SSDP must receive continual education per year to maintain licensure and/or to continually be involved with educational opportunities.
• Assist in providing scheduled and/or spontaneous education for families, residents, and staff.
• Educate by modeling appropriate interactions and approaches.
• Model and teach by being a presence on the floors.

Daily Life of Social Service Program

• Provide clean, safe, non-hazardous units for the residents and staff.
• Facilitate family and community involvement, such as inviting the families and community into the facility to assist in enriching the residents’ lives and/or being a part of the discharge process.
• Directly supervise all assigned staff to ensure continuity of care within the IDT.

Marketing the Social Service Program

• Develop and maintain relationships with all area’s senior services, organizations, health care services, and community services.
• Develop and maintain a marketing collateral and communication with all appropriate area organizations, healthcare services, and other professionals to enhance the facility’s discharge potential portfolio.
• Become a knowledgeable and experienced leader in the area in regards to the social service field and the program.

Other

• Perform any other related or necessary duties that would promote or execute the needs of the Social Service Program, the facility, the Administrator, DON, Corporate Coordinator of the Social Services Program, Director of Operations of Clinical Programs, corporate, and/or the residents or their responsible parties.