Description
Provide nursing home residents and their families with psychosocial support to adjust to long-term, post-acute, or end-of-life care; deliver counseling, advocacy, and case management; coordinate discharge planning; connect to community resources and benefits; collaborate with the interdisciplinary team; and ensure documentation and compliance with Medicare/Medicaid and state regulations.
- • Collaborate with the interdisciplinary care team to assess residents' psychosocial needs and integrate them into care plans.
- • Conduct comprehensive psychosocial assessments at admission, quarterly, and with significant change.
- • Identify and report suspected elder abuse, neglect, or exploitation and initiate protective actions.
- • Provide individual and group counseling to help residents adjust to long-term care, illness, grief, and behavioral health needs.
- • Facilitate care conferences, family meetings, and support groups to improve understanding and coping.
- • Advocate for residents' rights and resolve crises, conflicts, or grievances.
- • Assess environmental and social barriers within the facility and family system that affect resident progress.
- • Use assessments and consultation to plan, coordinate, and monitor psychosocial interventions and rehabilitation.
- • Update care plans as residents' medical, cognitive, or psychosocial status changes.
- • Track, evaluate, and document resident outcomes and services according to measurable goals and regulatory standards.
- • Supervise social services assistants, interns, or volunteers as assigned.
- • Contribute to facility policies and quality improvement initiatives for psychosocial care.
- • Assist residents and families with Medicare and Medicaid eligibility, documentation, and appeals related to long-term care.
- • Complete required MDS 3.0 mood and behavior interviews and social services documentation.
- • Develop or coordinate programs addressing isolation, dementia-related behaviors, substance use, and community reintegration.
- • Plan and execute safe discharges or transfers to home, assisted living, hospital, or other care settings, arranging services and equipment.
- • Educate residents and families about advance directives, hospice, palliative care, and end-of-life options.
- • Maintain accurate records and prepare for state, federal, and accreditation surveys and audits.
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Healthcare & Human Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
