Social Worker – Discharge Planner

Coordinate and manage the discharge planning process for residents by conducting psychosocial assessments and interviews. Develop individualized discharge plans based on each resident's needs and goals while arranging post-discharge services, equipment, transportation, and community resources. Communicate with hospitals, home health agencies, and interdisciplinary team members to facilitate safe transitions, providing education and support regarding available resources. Participate in care plan meetings and maintain accurate documentation in accordance with facility policies. Advocate for residents while promoting independence, dignity, and continuity of care.