The role of the social worker in a long-term care facility is to enable each individual to function at the highest possible level of social and emotional wellness. For our short-term rehab patients, our social workers focus on facilitating discharge planning, including the coordination of home health or hospice services, equipment needs, and community services. For our long-term residents, our social workers help residents make the transition from living at home or in an assisted living community. Once a resident is admitted, the social worker assures the resident's continuing needs are met and that the person is given the opportunity to participate in planning for continued care in the facility, transfer, or discharge back into the community. Although the resident is the main focus, it should be noted that much of the social worker’s time may be spent working with the family.