Provides assistance to patients/support systems and the multidisciplinary teams to identify, provide information, and facilitate access to tangible and supportive services related to patient health care needs.

1. Needs Assessment:

• In Collaboration with care team, conduct evaluations of client needs through interviews and assessments

• In Collaboration with care team identify barriers to accessing resources and develop strategies to address them

2. Resource Coordination:

• Connect patients with appropriate services such as housing, healthcare, food assistance, transportation, and employment programs.

• Maintain an up-to-date knowledge of local community resources and eligibility criteria.

• Educate clients on available services and how to access them independently

• Identifies available transportation resources and collaborates with patient/support system for cost effective, safe transportation

3. Advocacy:

• Advocate for patients to have knowledge to support access to resources and services they are entitled to

• Advocates/supports access for patients to skilled, acute or long-term care facilities

4. Compliance and Documentation:

• Delivers Important Message from Medicare/Discharge Rights

• Collaborate to support completion of application process to obtain resources and with completion of Advanced Directive Care Planning

• Document case details in compliance with organizational policies.

5. Collaboration:

• Work closely with social workers, counselors, and other professionals to support discharge planning and care transitions

• Attend inter-disciplinary rounds or unit huddles to strengthen relationships and improve resource access for patients.

6. Administrative Tasks:

• Maintain accurate records and reports.

• Provide communication of resource availability for transitions of care to include unit phone support, e-mail communications, and direct patient meetings

7. Performs other duties as required or assigned.

• Bachelor's degree in Social Work or Human Service field or the equivalent in education and experience required.
• Excellent interpersonal, communication, and organizational skills required.

• None