Social Services and Discharge Planning

Supporting Residents and Families Throughout the Care Journey

At Fresh River Healthcare, Social Services is an essential part of our interdisciplinary approach to care. Our Social Services team helps residents and families navigate the healthcare journey by providing advocacy, emotional support, care coordination, discharge planning, and access to valuable community resources.

Located in East Windsor, Connecticut and serving Greater Hartford and Northern Connecticut, Fresh River Healthcare supports individuals receiving short-term rehabilitation, skilled nursing care, Huntington’s Disease services, Parkinson’s Disease support, memory care, behavioral health services, and long-term care.

Our goal is to help residents and families feel informed, supported, and connected throughout every stage of care.

Resident and Family Support

Adjusting to a healthcare setting can be challenging for residents and loved ones alike. Our Social Services team works closely with residents, families, nursing staff, rehabilitation professionals, physicians, and community providers to help address concerns, facilitate communication, and support individualized care planning.

Services may include:

• Resident and family counseling

• Care plan participation

• Family communication and support

• Resident advocacy

• Advance care planning

• Healthcare decision-making support

• Community resource coordination

• Emotional support during transitions

• Assistance navigating healthcare systems

We strive to ensure that residents’ preferences, goals, dignity, and quality of life remain central to every aspect of care.

Discharge Planning and Transition Support

Discharge planning begins early for residents admitted for short-term rehabilitation or post-hospital recovery. Our Social Services team collaborates with residents, families, therapy staff, nursing staff, physicians, and community providers to help coordinate a safe and successful transition when discharge is appropriate.

Discharge planning services may include:

• Home care coordination

• Durable medical equipment arrangements

• Follow-up healthcare appointments

• Transportation planning

• Medication coordination

• Community service referrals

• Long-term care planning

• Behavioral health referrals

• Caregiver support resources

Our goal is to help residents and families feel prepared and supported throughout the transition process.

Community Partnerships and Wraparound Services

Fresh River Healthcare recognizes that successful transitions often require more than medical care alone. Through partnerships with local non-profit organizations, community agencies, housing resources, and service providers, we help connect residents with important supports that promote stability and long-term success.

Depending on individual needs, our team may assist with access to:

• Housing and transitional living resources

• Clothing and personal necessities

• State-issued identification and documentation

• Community behavioral health services

• Substance use recovery resources

• Transportation assistance

• Benefits and entitlement programs

• Community case management

• Financial and social service resources

• Ongoing support services following discharge

These partnerships help ensure residents have access to the resources necessary to support their health, independence, and well-being both during their stay and after returning to the community.

Specialized Support for Neurological and Behavioral Health Programs

Fresh River Healthcare’s Social Services team has experience supporting residents living with Huntington’s Disease, Parkinson’s Disease, dementia, behavioral health conditions, and other complex medical or neurological diagnoses.

Our staff understands the unique challenges these conditions may create for residents and families and works collaboratively to help address emotional, social, financial, and community-based needs.

This support extends beyond the resident’s clinical care and includes helping families identify resources, navigate systems, and plan for evolving care needs over time.

Person-Centered Advocacy

At Fresh River Healthcare, every resident deserves to be heard, respected, and supported. Social Services plays an important role in advocating for residents while helping ensure care plans reflect individual preferences, values, goals, and life experiences.

We believe that successful care depends on collaboration, communication, and respect for each person’s unique circumstances.

Learn More About Social Services at Fresh River Healthcare

To learn more about Social Services, discharge planning, community resources, rehabilitation services, skilled nursing care, or admissions at Fresh River Healthcare, please contact our admissions team.

We are committed to supporting residents and families through every stage of the healthcare journey with compassion, professionalism, and person-centered care.