Social Services, Resident Supports and Discharge Planning

Social Services

Chelsea Place Care Center’s Social Services team plays an important role in supporting residents and families throughout the care journey. Our social workers help residents adjust to the care environment, navigate transitions, access resources, and maintain the highest possible quality of life during their stay.

Social services are integrated throughout the resident experience and work closely alongside nursing, rehabilitation, admissions, activities, dietary services, and clinical providers to support individualized, person-centered care.

Resident and Family Support

The transition into a skilled nursing or rehabilitation setting can often feel overwhelming for residents and families. Our Social Services team helps provide guidance, communication, advocacy, emotional support, and care coordination throughout the admission process and beyond.

Social services support may include:

• Resident and family counseling
• Care plan participation
• Discharge and transition planning
• Coordination with outside agencies and providers
• Advance directive support
• Insurance and resource guidance
• Behavioral and emotional support
• Family communication and education
• Resident advocacy
• Community resource coordination

Our goal is to help residents and families feel informed, supported, and actively involved in the care planning process.

Community Partnerships and Transitional Support

Chelsea Place Care Center maintains relationships with local non-profit organizations, community service agencies, housing resources, and transitional support programs throughout the Greater Hartford area. These partnerships help support residents who may require additional assistance both during their stay and as part of discharge planning.

Depending on individual needs, our team may help coordinate access to:

• Housing and transitional living resources
• Clothing and personal necessities
• State-issued identification and documentation assistance
• Community behavioral health services
• Substance use recovery resources
• Transportation coordination
• Financial and benefits assistance
• Follow-up medical and social service appointments
• Community case management and support services

Our Social Services team recognizes that successful transitions often require more than medical care alone. We work collaboratively with community partners to help residents access supportive services and resources that promote stability, continuity, and long-term success following discharge whenever possible.

Discharge Planning and Care Coordination

For residents admitted for short-term rehabilitation or post-hospital recovery, discharge planning begins early during the stay. Our Social Services team collaborates with residents, families, therapy staff, nursing, physicians, and community providers to help coordinate a safe and appropriate transition following discharge whenever possible.

This may include coordination of:

• Home care services
• Durable medical equipment
• Community resources
• Follow-up appointments
• Transportation arrangements
• Long term care planning
• Behavioral health and social service referrals

Person-Centered Care

Chelsea Place Care Center is committed to treating every resident with dignity, compassion, and respect. Social Services helps support that mission by advocating for residents’ preferences, goals, emotional well-being, and quality of life throughout their stay.

Our team recognizes that every resident’s situation is unique, and we strive to provide individualized support that reflects each person’s needs, background, and personal goals.

Learn More About Chelsea Place Care Center

To learn more about social services, rehabilitation, skilled nursing care, or admissions at Chelsea Place Care Center, please contact our admissions team. We are available to assist residents, families, hospitals, and community providers with questions about services and care planning.