Role of the Social Worker in Long-Term Care

Jessica Luckett
Social Services and Business Office
Southern Hills Skilled Nursing & Rehab

Social work within a nursing facility is to provide additional support to the resident and their families. Coming into a nursing facility can be hard especially if a resident needs to stay long term care. The social worker can help set up counseling services for residents that may be struggling with their change of condition from their health or mental health. Even if a patient is coming into a nursing home for therapy services, it can be hard especially when the patient is used to being very independent. Counseling can help with this. Social worker can also help set up ancillary services as well. Residents might have a hard time getting out to see an eye doctor or podiatrist and the facility tries to make it easier by having services like this come into the building. The social worker can also be a resource to residents and families when they have questions in regards to their care, policies and in general on the process of coming into a facility. It can be very over-whelming when someone has never been to a facility before. It is hard to know what to expect and what happens next.

A social worker is here for the resident and families to help in any way possible. They may need to be an advocate on the resident’s behalf if the resident is having a hard time saying what they want to their families. A resident could want hospice but the family disagrees and a social worker is there to help the resident find the words and encourage them to speak with their family. This could also be when trying to decide on going home. A resident could want to go home but the family doesn’t want them back home. As long as the resident is safe to discharge back home, the social worker will help the resident get back there. That will also include setting them up for home health services. A resident is deemed safe by the inter-disciplinary team. This team consists of nursing, therapy and social services. If a resident is in need of additional services at home, social services will help set this up. These services could be done by family members or friends providing added care in the home to make it safe.

Social workers are to help residents with the transition from the hospital to the facility and then the transfer from the facility to home. The goal is to make a smooth transition all around. It does not always happen but the social worker is there to try and fix and smooth any bumps that could have occurred during the transition. Some difficulties with the transition to the facility, sometimes a resident’s transport is late and the resident arrives late or even in the middle of the night. Also if a physician at the hospital changed their medications and the resident was unaware, the resident can get confused on why the facility is now giving them a new medication. Some difficulties when transitioning home can be home health is not able to see the resident until a few days after discharge. Also, when ordering equipment, it can take longer to be delivered due to the high demand of wheelchairs and even bedside commodes. It can be difficult then for a resident to get around at home.

Social workers are here to help a resident to transition to long term care, transition home, to get additional services that are being requested or just even a listening ear when a resident is having a rough day. Social workers may not have all the answers but they are a staff member to go to as a resource for a resident or family.