Interviews patient/patient's social support system to complete initiate psychosocial evaluation. Provides counseling/support/education to patient/patient's social support system. Assists patients/patient's social support system in coping with stress related to hospitalization, disability, chronic/terminal illness. Works collaboratively with the patients and patient's social support system to establish and implement a plan of care with multidisciplinary team that meets the patient's identified psychosocial needs. Serves as a resource to hospital staff and physicians regarding emotional, social, and psychosocial components of the patient's illness and its effects on their social support system. Assists and facilitates the multidisciplinary team in understanding and integrating these aspects into the plan of care. Intervenes in crisis situations, appropriately and effectively applying crisis intervention theory' and skills Completes psychosocial assessments for the patient's post hospital care for designated patient's and their support system. Works with the Clinical Care Management team to assess and evaluate the patient/patient's social support system for the appropriate level of care or environment setting to meet care needs across the continuum. Participates in multidisciplinary care planning meetings. Maintains current knowledge and researches availability of community agencies and community resources for social, emotional or financial assistance. Provides information, education to patients and their social support on community resources and options for post hospital care appropriate to the age of the patients served, in collaboration with the Clinical Care Management team. Make referrals to community agencies as needed. Reports suspected cases of child & adult abuse/neglect/exploitation. Serves as liaison between hospital, patients/patient's social support system and Department of Social Services during evaluation/investigation. Identifies and records clinical, psychosocial and financial barriers to a smooth transition across the healthcare continuum and assists in identifying and facilitating system improvements. Works with Clinical Care Management leadership to identify problems, recommended solutions and works toward resolution. Develops and maintains accurate case records of each referred patient. Documents in medical record according to departmental standards.