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 electronic me...