This article is sponsored by Centers Health Care. In this Voices interview, Skilled Nursing News sits down with Kenny Rozenberg, CEO of Centers Health Care, to explore the critical role of social workers in skilled nursing facilities. Rozenberg discusses how Centers Health Care integrates social workers into interdisciplinary care teams, leveraging their expertise to enhance care transitions, reduce hospital readmissions, and provide crisis intervention support for residents and families. He also highlights the challenges social workers face in long-term care and shares insights on how SNFs and policymakers can better support these essential team members.
Skilled Nursing News: What is your background, and how did it lead to your role today?
Kenny Rozenberg: I started my career as an EMT, and that experience really shaped how I see health care. Being on the front lines, responding to emergencies and helping people in their most vulnerable moments gave me a deep understanding of what quality care looks like. It also taught me the importance of quick decision-making, teamwork and always putting the patient first. Over time, I wanted to make an impact on a larger scale, so I transitioned into the operational side of health care. I became engaged in skilled nursing and saw the opportunity to improve care and services for people who need long-term support. That led me to found Centers Health Care, where I serve as CEO, working to expand and enhance the services we provide to ensure the highest level of care for our patients and residents across our 45 locations throughout the Northeast.
How can hospital and skilled nursing facility social workers work together to strengthen their partnership and improve patient transitions?
Building a stronger partnerships between hospital and skilled nursing facility (SNF) social workers starts with consistent communication and collaboration. Establishing direct lines of contact with—whether through designated liaisons, shared contact lists, or regular check-ins—helps streamline the referral process and reduce delays.
Early coordination is key, so involving SNF social workers in discharge planning discussions as soon as a patient is identified for transfer allows for better alignment on care needs, insurance coverage and family concerns. It also helps hospital partners to provide SNFs with detailed patient histories, including medical, social and behavioral backgrounds in order to ensure facilities can adequately prepare the right level of care and support.
Additionally, our system likes to encourage joint training sessions and case review meetings because that helps both teams stay aligned with best practices, regulatory updates and community resources.
What strategies does Centers Health Care use to ensure its own social workers are effectively integrated into the care team?
We are intentional about making sure social workers are fully integrated into the care team across all of our facilities at Centers Health Care by fostering strong communication and collaboration. For example, they’re involved in care planning from day one, working alongside nurses, therapists and doctors to ensure a holistic approach to each resident’s needs. We hold regular interdisciplinary meetings where social workers provide input on care plans, advocate for residents and help address any social or emotional challenges that could impact recovery. We also invest in ongoing training and professional development, so they stay up to date on best practices and resources.
Beyond that, we create a culture where our social workers know their role is valued—not just as support staff, but as key decision-makers in a resident’s journey. By making them a core part of the team, we ensure they can provide the best possible support to our residents and families.
How can hospital and SNF social workers work together to provide support and education to families during the patient’s transition to a nursing facility?
Transitioning a loved one to a nursing facility can be an emotional and overwhelming experience for families, and strong collaboration between hospital and skilled nursing social workers is key to providing the support they need. Open and proactive communication helps set clear expectations about the transition process, including what families can anticipate in terms of care, daily routines and ongoing medical needs.
Social workers can work together to offer educational sessions, one-on-one meetings, or written resources that explain insurance coverage, resident rights and ways to stay actively involved in their loved one’s care. Empathy is essential. Checking in with families, addressing their concerns and reassuring them that their loved one will receive quality care can ease anxieties. A warm handoff, where the hospital social worker personally introduces the SNF social worker to the family, goes a long way toward building trust and continuity. By partnering in this way, social workers ensure that families feel informed, supported, and confident in the transition process.
How do they specifically contribute to reducing hospital re-admissions and improving care transitions?
Across the industry, social workers play a vital role in reducing hospital readmissions and improving care transitions by ensuring residents receive coordinated, proactive support before, during, and after discharge. They work to address both clinical and social factors, which often include the coordination of follow-up care, ensuring medication adherence and connecting residents with necessary home health services. Industry-wide, successful transitions rely on strong hospital partnerships, effective discharge planning and comprehensive resident education to prevent avoidable rehospitalizations.
We’ve built a system that’s designed to give people holistic care, so we embed our social workers deeply into our interdisciplinary teams from day one. This helps to ensure they are actively involved in care planning from admission through discharge. We also make it possible for them to follow cases in real-time, team up with other care providers and address the everyday challenges like access to food or stable housing that can impact the well-being of our residents. By leveraging our network of resources and prioritizing hands-on, personalized transition support, we help residents achieve safer, more stable recoveries while minimizing hospital returns.
How can social workers collaborate to address complex social issues that may impact patients’ care and transition?
Dramatic shifts in nursing home resident demographics have led to a growing demand for specialized care. Addressing these complex social issues requires a unified approach between hospital and SNF social workers. Open communication and shared case management helps to ensure that no critical details are lost during transitions, while early identification of social challenges aids in creating a proactive care plan.
For patients facing homelessness, social workers can work together to secure safe discharge options, whether through transitional housing, specialized nursing facilities or shelter programs with medical support. When substance abuse is a factor, connecting patients with addiction treatment services, counseling and long-term recovery programs can provide stability beyond their immediate medical needs. In cases of domestic violence, social workers must prioritize patient safety, discreetly coordinating with protective services and advocacy groups to develop a safe transition plan. By leaning on each other’s expertise and tapping into local resources, social workers can provide not just medical continuity, but also the social support systems patients need to heal and regain stability.
Finish this sentence: “In 2025, the skilled nursing industry will be defined by…”
…a stronger emphasis on integrated, person-centered care to address increase in complex patient needs and enhance quality outcomes.
Facilities will need to focus on improving care coordination across disciplines, ensuring social workers, nurses and therapists work seamlessly together to address both medical and social determinants of health.
Finding qualified and compassionate social and clinical staff for our aging loved ones will also continue to be a top priority, requiring competitive wages, career development opportunities and a focus on workplace cultures that prioritize employee well-being.
At the same time, technology—whether through AI-driven care planning, telehealth expansion, or enhanced EHR systems—will play a key role in improving efficiency and patient outcomes. Success in 2025 will depend on how well facilities adapt to these shifts while maintaining a strong commitment to high-quality care.
Editor’s note: This interview has been edited for length and clarity.
Learn more about Centers Health Care at https://centershealthcare.com/.
The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact [email protected].
