The Challenges and Rewards of Social Work in the Post-Acute Care World

On the day that Martine Center 81-year-old Charles Lightner was discharged from the 400-bed White Plains skilled nursing facility on March 4, 2025, the facility's Director of Social Work, Nicole Vaughan, visited Charles a number of times to make sure he was ready and set to go home. Mr. Lightner had been suffering from hypotension or low blood pressure where he often got dizzy, leading him to several falls he had. Nicole always makes sure as she tours the 200-bed skilled nursing facility, that her residents are comfortable and she loves having pleasant conversations with them, asking them "how are they doing", undoubtedly a comfortable presence to have at the beginning of each day. According to Ms. Vaughan, Mr. Lightner was one resident that she got to know and had a solid friendship with.

A divorced former accountant, Charles has a son, daughter-in-law, and four-year-old grandson living in Philadelphia. Charles worked for the New York City Metropolitan Transit Authority (MTA) in midtown Manhattan and during tax season for over a decade, he also worked for H&R Block. Charles came to the Martine Center from White Plains Hospital for physical and occupational therapy right before Christmas last year. Following his eviction, Mr. Lightner, who now has two incomes, had been living in SpringHill Suites Tuckahoe Westchester County Marriott Hotel in Tuckahoe. Over the six months, he was having low iron deficiency issues, where his blood pressure would drop, leading to his dizzy spells, and then he would pass out.

Charles said this first happened one day when he took the Metro North train and passed out on the ride. More dizzy spells and passing out would follow but on that day, he was taken to NYU Langone Medical Center and then transferred to White Plains Hospital. Mr. Lightner is also a heart patient at Columbia Presbyterian in Upper Manhattan. On the morning of his discharge from Martine Center, he not only praised the therapy and nursing at the facility but also felt at ease every day because Nicole knew his history.

"She's been terrific and has done a lot for me," said Mr. Lightner. "Nicole has also spoken to my ex-wife and son, so it's been very good. She really knew of my needs while staying here and was able to get all of my reservations taken care of quickly."

From Martine Center, Charles headed back to the Marriott and also plans to do outpatient rehabilitation when he gets re-settled. He is in very good shape, loves to take walks, and has been leisurely playing tennis for the past few years. In his downtime, you can find Mr. Lighnter at the hotel's computer suite.

An experienced Director of Social Services, Nicole Vaughan has spent fifteen years in the field of social work. A once Brooklyn community leader, community organizer, and motivational counselor , Nicole Vaughan came to the Martine Center this past January. When arriving, her biggest challenge was getting used to the work environment at Martine Center, a significant new setting from her years in Brooklyn. She knows the field of social work so well, where it is so natural to her, even without thinking about it, this alone carried her through the re-learning period at Martine Center, that she refers to it as having "muscle memory". A case manager, mentor, family advocate, and an established author, Ms. Vaughan was a successful outreach worker and liaison in Red Hook where she worked with families who had loved ones who were intravenous drug users. She was also a gang awareness counselor for youths, a family counselor, community organizer, and was an advocate for families in these situations. Ms. Vaughan came from assisted living facilities.

"I love being a social worker, but it's extremely demanding, and you must always hit the ground running," said Ms. Vaughan.

Ms. Vaughan developed her experience as a human services professional and community organizer for twenty years, giving her the basis of being a successful social worker.Giving it an industry perspective, Nicole says social work is all about family's expectations and emotions. With families, what is often expected can be unrealistic regarding their loved ones' actual direction. Whether it is returning to their home and to their community, that may not happen now, in either the short-term future, or even the long-term. High expectations, if not discussed, can be damaging. Nicole knows this so it's best to be easily upfront with families every step of the way.

"You ask any social worker, and they will say that family expectations are the most challenging part of the day. You have to know that families have their own denials of what is before them, and many times, they have false expectations in this industry and the operations at skilled nursing facilities. They have understandable emotions, and many families come to the point of needing professional support and transitioning care for their loved ones. Most of it is based on emotions and understand-ably, most families don't know how to accept the fact that their loved one is now in this next chapter and transition of care. Social workers work with families and residents, it's care from the heart, not clinical."

With Charles, Nicole's relationship with him clicked nicely where she learned and understood his family dynamics, making it a natural progression. In many ways, Charles' case has been a strong blueprint of a Nicole Vaughan successful social work outcome. Even so, Nicole explains the best ways and tactics for connecting to a loved one's family from a social worker's point of view.

"It's better to have deep emotional conversations with the families in-person, not over the phone, says Nicole. Social Workers need to read facial and body language for the communication to go as best as it can be. It's life-changing and emotional, you have to be sympathetic and empathetic in this career. We all want to spend time with our families during holidays and birthdays. It is essential and sometimes life changes all of that.

The dynamics of social work's role at all healthcare institutions is key for families. It's important to note that families and their communities understand that social work is the bridge between clinical staff, i.e., nurses and therapists, and the families. Social workers work with both nursing and rehabilitation departments from the day of admission to discharge. For long-term residents, social workers make their stay as comfortable as it can be daily. Short-term residents don't sign off on residents' discharge, but they are the ones who meet with the clinical staff who would officially sign off. Following proper sign-offs, social workers can speak to the families and make the discharge as easy as possible, leading to a happy ending. Such was Charles Lightner's case, so the emotional and practical sides of social work, nursing, and therapy always need to work together.