A Social Worker’s job is to “to attain or maintain the highest practical physical, mental, and
psychosocial well—being of each resident.” This means Social Workers can help with
everything from counseling and providing emotional support, assistance in communicating with
staff and other residents, and provide encouragement to engage in community life at our facility.
In a skilled nursing facility, Social Workers provide services to two very different populations,
long term care residents and short-term rehab patients. Often, the Social Worker’s role involves
helping patients and families decide between the two populations.
Long Term Care residents are those who live at the facility and have physical and/or cognitive
needs that cannot be met at home. Social Workers provide reminders and cues to residents
and help residents carry out tasks that they are no longer able to, like making phone calls and
managing their finances.
Short Term patients have an acute need and are staying at the facility temporarily until they are
able to go home. They may struggle with mood issues, like anxiety and depression, and a
temporary loss of control when they find themselves with an injury or illness. Social Workers
can help patients feel empowered to deal with their new circumstances.
Hancock Hall and Filosa understands that choosing nursing home care for your loved ones is an
emotional decision. For more than 70 years, we have helped patients and families. During that
time, the role of the Social Worker has changed dramatically.
Keep reading about the role social workers play in nursing homes and be confident in the care
your loved one will receive.
History of Social Work
Social Work began in the 1800s with the appearance of “friendly visitors” in people’s homes to
check on their general welfare and improve their condition. Skilled nursing facilities are
considered home to our residents and our Social Workers do the same. They may sit with
residents and hold a hand, provide supportive listening during a sad moment, or help find lost
glasses or a sweater. But Social Work has evolved in the 21st century to become so much more!
They provide Case Management services which involves insurance updates, billing issues and
eligibility for special services like Medicaid or Meals on Wheels and Discharge Planning which
involves referring for Visiting Nurse services, ordering Durable Medical Equipment and
coordinating medical appointments.
Social Work Education
Social Workers in a SNF must have at minimum a Bachelor’s of Social Work degree or in a
related field such as Sociology or Public Health. A Master’s level Social Worker will provide
consultation or oversight to the facility. In addition, many graduate level Social Workers choose
to take an exam to become Licensed, either as a post-graduate LMSW (Licensed Master’s of
Social Work) or with 3000 hours’ experience, an LCSW. An LCSW, or License Clinical Social
Worker, may provide psychotherapy in a private setting and is certainly skilled in assessment of
our patients’ mood, cognition and behaviors in the SNF.
Short Term Rehab vs Long Term Care
Short Term Rehab can be a very challenging and confusing time for a patient and family,
particularly when it is unplanned. You may have questions like what help does my insurance
cover at home, how do I get more help if it’s not covered, where will I buy a wheelchair or how
do I get to and from my doctor’s appointments. A Social worker is able to answer all these
questions! Our goal is to provide a comprehensive discharge plan that includes referring to
visiting nurse services, ordering Durable Medical Equipment and setting up additional caregiving
services to optimize our patient’s success at home.
Sometimes folks have services at home but for whatever reasons- financial, family or otherwise-
it’s just not enough. Our facilities provide Long Term Care for people whose needs cannot be
met at home. Making this decision is often full of angst and guilt. Or Social Workers are
equipped at providing reassurance and helping families evaluate where the patient’s needs are
best met and why.
Social Workers also help the patients, who often have some cognitive and
mood issues, to understand and come to grips with the need for their placement. Social Workers will lead the patient and family towards the activities in the facility that will optimize their quality of life, whether it be the garden outdoors, a religious activity, or a compatible roommate
More often than not, long term care residents acclimate very nicely and enjoy their new routine in our facilities. Their families may struggle with accepting these changes as they miss the previous routine. Social Workers spend a lot of time listening to and supporting family members as they adjust, helping them explore options and weighing the pros and cons of care for their loved ones. Social Workers typically have an Open-Door policy and are available to families throughout the day. Social Workers can also organize Support Groups and direct families to other family members who have recently gone through the same challenges.
Sometime our patients and families don’t know where to go with a question. Our Social
Workers may not have all the answers – though they have most- but they can direct you to the
person who will be able to answer the question, whether it’s the Business Office to answer a
billing question or Maintenance to fix a broken light. Similarly, staff may struggle to find an
answer or recommendation for a patient and turn to the Social Worker. Perhaps, the patient
has an uncommon insurance and needs help finding a medical provider. Or maybe the staff is
having difficulty getting a response from another agency. The Social Worker can use this
communication strategies and training to resolve the issue. Also, Nursing facility staff,
especially during and after COVID times, carry some stress and burden. Social Workers can
provide support to their co-workers by offering listening and reminding them of self-care
All social workers act as an advocate for their patients. It is a core part of the role. They have
ability to effect positive change in the lives of their [patients and provide voice for those who
cannot advocate for themselves.
Advocating for a patient doesn’t stop at treatment goals and patient rights. A nursing home social worker may also advocate for new pillows, decorations to make their room feel like home, or an outing somewhere. A social worker may also advocate for continued insurance coverage, increased Independence or an alternative meal. Social Workers will continue to brainstorm until the solution puts a smile on someone’s face.
Social Workers complete Medicare required documentation for residents, including notes on mood, cognition and behaviors. As it is well-known in this field, if it’s not documented, it’s not done! In addition, Social Workers can assist patient and families with documentation for many related purposes, for example, completing Advance Directives like Power of Attorney and Health Care Proxy. Social workers can help initiate those difficult conversation about what patient want for themselves at the end of their life.
Also, Social Workers can help with the completion of forms, which is often a daunting task while dealing with an illness, like applying for Medicaid, updating insurance of ordering medical supplies.
Putting the Puzzle Pieces Together
The decision to place the care of a loved one in the hands of another is never easy. But we are not all equipped to provide nursing care at home. And the caregiving role for families doesn’t end here. Social Workers continue to walk with patients and families on their journey as they become acclimated to life in this setting and help find the answers as each question arises. They may not always have the answers- though they have most- but they will keep looking until the find it. It’s like putting together a puzzle. Social Workers will not rest until all the pieces are put together.
Contact us today to meet our nursing home social workers and feel at ease with the care and
treatment your loved one will receive.