This review article discusses the critical role of social services in helping families care effectively for long-stay patients following discharge from hospital. Conscious that there are complexities that surround long stay patients, the article evaluates how integrated social service interventions promote coordinated care, improve patient discharge planning, and close the gap between hospital and home environment. Such important factors as communication, cultural competence and allocation of resources are discussed to point out their influence on the families’ willingness to support patients after discharge. The research shows that high social support systems enhance health outcomes, decreases readmission rate, and makes the transition to community care easier. However, such persistent barriers; including lack of funding, lack of staff, and systemic fragmentation impede the effectiveness of social services. Through the identification of these barriers, the review highlights the need for improved collaboration between healthcare providers, social workers and community organisations. It requires further studies to shed more light on the dynamics of social services and their effects on patients and families experience, which in the end would call for policies that favor creation of equitable access and comprehensive support mechanisms for long-stay patients and caregivers.