April 7, 2021

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General Overview:

The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.  Medically-related social services are services provided by the facility’s staff to assist residents in maintaining or improving their ability to manage everyday physical, mental, and psychosocial needs.

The facility will employ qualified social workers on a full-time basis.  A qualified social worker is an individual with:

1. A minimum of bachelor’s degree in social work or a bachelor’s degree in a human services field including but not limited to sociology, gerontology, special education, rehabilitation counseling, and psychology. 
2. The facility may also employee Social Service techs with less than a bachelor’s degrees in a related field but only under the supervision of a licensed Social Worker. 
3. The facilities also partner with local colleges to provide opportunities for field placements.  Social Service students may be trained by multiple members of the Social Work Department but are directly overseen by the Social Work Director.    
4. All Premier facilities will have a Social Work Director who reports to the facility Administrator, oversees the job performance of the members of the Social Service Department, follows up on all concerns/quality measures as requested by the Corporate Social Worker and ensures that all changes and updates in regulations and policies are implemented.

Social Service Department Members:

1. The Social Worker/Designee, will complete an initial, quarterly, annual and as otherwise required assessments/ MDSs of each resident.  The assessment should identify any need for medically-related social services of the resident.  Any need for medically-related social services will be documented in the medical record and addressed accordingly with a plan of care.
2. The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services of the resident.  Examples of medically related needs are as followed but no limited to: 
   1. Making arrangement for obtaining needed adaptive equipment, clothing, and personal items
   2. Promoting contact with the interdisciplinary team (with the resident’s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning.
   3. Through the assessment and care planning process, identifying and seeking ways to support residents’ individual needs and promoting patient center plans of care. 
   4. Assisting staff to inform residents, and those they designate, about the resident’s health status and health care choices and their ramifications
   5. Making referrals and obtaining services from outside entities (e.g. ,legal services, vision and hearing assessments, long term care ombudsman services,  insurance issues, etc)
   6. Assisting residents with personal, financial and legal matters as applicable.
   7. Providing or arranging provision of needed counseling services by obtaining need consults with both psychiatry and psychology services within the facility and outside the facility as requested.
   8. Promoting actions by staff that maintain or enhance each resident’s dignity in full recognition of each resident’s individuality
   1. Assisting residents to determine how they would like to make decisions about their health care, and whether they would like anyone else to be involved in those decisions.  The Social Worker will hold Advanced Care planning meetings with residents/families.
   10. Providing counseling services regarding Hospice options.
   11. Providing alternatives to drug therapy by understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet.

1)  Completing a Root Cause Analysis of all psychotropic medications prior to      the 5 day MDS initial assessment.

2)  Logging for the physician possible alternative options including GDRs of medication as indicated.

3)  Participating in the Monthly Behavior Monitoring meeting to continually reassess the need to address resident’s mental health concerns as well as the need to decrease medications as able.

      3.  Meeting the needs of residents who are grieving, suffering from Trauma or alcohol/drug

            addiction.   Providing supportive visits in conjunction with applicable formal psych services.

 

      4.  The Social Worker is required to initiate and continually updated care plans that reflect any

            ongoing medically-related social service needs, and how these needs are being addressed.

 

      5.  The Social Worker will monitor the resident’s progress in improving physical, mental, and

             psychosocial functioning.

 

      6.  The Social Worker is responsible to coordinate and attend all care conferences to be held

            both quarterly and whenever requested by a resident or designated representative.  

 

      7.   The Social Worker is required to address Advanced Directive concerns as indicated and obtaining

            Guardianship as applicable.

 

      7.    Discharge planning services promoting person centered are and resident preferences.

a) A discharge plan of care will be developed as directed by patient preference to   discharge to the prior environment or least restrictive environment.

b) Social Services with assist with arranging all applicable services in the community to promote the targeted discharge location.

c)  Social Services will coordinate all supportive services prior to discharge including but not limited to: Meals on wheels, life line, transportation, medical equipment, pharmacy services, outpatient therapies, skilled home health care, Assisted Living/AFC transfers, obtaining Medicaid and VA benefits and private duty services.

d) Social Services is responsible to provide all residents/designated representatives with their rights to appeal any change in coverage as indicated by regulations.

e)  Monitor and address all concerns pertaining to insurance coverage.

 

      8.    The Social Worker will perform clinical testing and assessment of mental health issues as

             indicated including but not limited to: BIMS, PHQ9, MMSE, CAM, LEC, GAD-7 and Suicide

             Risk Analysis.  

      9.   Case managers fall under the umbrella of the Social Service Department and are responsible

            to address all coverage needs through all types of insurance and report directly back to the

            Administrators and Social Workers of each building.   The case managers may be located

           offsite and are responsible for all communications to all involved disciplines.

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