Nursing Home Social Services Reference/Flow of Care/Hospitalization

The social services department is involved in the hospitalization of residents including transfers to/from hospital to skilled rehab and/or long-term care. These hospitalizations are interdisciplinary and involve almost all departments within the Nursing Home, even maintenance who prepares the room and may assist with moving the resident in/out if needed. In this section we will explore all aspects of a resident hospitalization in multiple scenarios. Transfer In, From Hospital to Skilled Rehab or Long-Term Care Move-ins are coordinated by admissions who collaborate directly with the hospital to ensure the NH has everything needed including medical documentation. Admissions are the primary and social services supports in any way needed. Once a resident arrives, social services meet with the resident and completes a psychosocial evaluation. If the resident is staying long term, the social services worker can answer any questions the resident may have about how the facility works or help to address concerns. Social services are far more involved in the discharge planning that begins the moment a resident transfer into the skilled rehab. Rehab is a short-term stay, and social services works to ensure they have the appropriate services and supports in place once they discharge. Entities' involved: Nursing staff and physicians within the facility Hospital social workers and discharge planners Rehabilitation therapists Transportation providers and external services Business office to facilitate financials Admissions to coordinate between Hospital and NH This interdisciplinary approach ensures that both medical and psychosocial needs are addressed throughout the transition. Transfer Out, From Nursing Home to Hospital If a resident's need for hospitalization is more acute or related to mental health, social services may have more of a hands-on involvement. For example, if a resident states they are having suicidal ideation, social services complete the necessary assessments needed for safety. If supports cannot be put in place at the Nursing Home and it is determined that psychiatric hospitalization is needed, social services will coordinate this with emergency dispatchers. Supporting Residents and Families During Hospitalization If a resident goes to the hospital, nursing and/or social services alert the family member or emergency contacts. Social services can provide the hospital with documentation and coordinate the residents return if needed. More often than not, social services are not needed except to relay their return date to the other departments in the NH to prepare for their return. Key responsibilities include: Maintaining communication with hospital social workers or case managers Providing updates to family members as appropriate Assisting families in understanding medical information and care decisions Advocating for the resident’s needs, preferences, and baseline functioning Return to the Facility from the Hospital Social services ensure there is open communication about the residents return date/time to the Nursing Home so that all departments can be ready for their return. Social workers collaborate with hospital teams to: Confirm the resident’s eligibility and readiness to return Coordinate transportation and admission timing Ensure that necessary equipment, medications, and services are in place Communicate any changes in condition or care needs to the Nursing Home team Regulatory and Compliance Considerations Reducing avoidable hospitalizations is key when it comes to quality metrics. Social services contribute by supporting advance care planning, supports are in place, acting as advocates, and helping residents and their involved parties make informed decisions about treatment preferences. Hospital transfers and readmissions are also closely monitored. Social services participate to ensure these processes are completed as smoothly as possible. Transitions are not always straightforward. Social workers frequently address barriers such as: Delays in insurance authorization or coverage issues Family disagreements, discharge plans Changes in level of care needs that require reassessment Limited bed availability or facility readiness Conclusion Social services department plays a vital role in managing and overseeing hospitalizations and care transitions in Nursing Homes. They ensure that communication remains clear, resident preferences are honored, and care remains coordinated. Their involvement not only improves the efficiency of transitions but also preserves the dignity and well-being of residents during some of the most vulnerable moments in their care.