Scope of Work:



To work collaboratively with members of an interdisciplinary team in order to assist patients and families with complex psychosocial needs. These interventions may include, but are not exclusive to: alternate site coordination, discharge planning, addressing all forms of identified abuse/neglect, adoption, substance use disorders, assisting with end of life decisions, providing appropriate referral resources, bereavement support, adjustment counseling, facilitating guardianships and behavioral health concerns (including psychiatric transfers).
+ Conducts psychosocial assessments with patient and or family to assist with identified psychosocial needs or who may be identified to require an alternate site of care post discharge and executes a plan.
+ Communicates with alternate sites of care and/or community agencies in an effective and timely manner, to best address the patient’s needs.
+ Completes and documents the assessment and plan in the...