Transitional Care: Support clients as they move from hospital or rehab settings back into the community—ensuring continuity, safety, and support every step of the way.
Care Plan Development and Implementation: Conduct initial and ongoing assessments of clients to document strengths, needs, goals and resources.
Connectivity to Care: Schedule and coordinate timely follow-up with primary care and behavioral health providers.
Addressing Gaps in Care: Identify missed appointments, medication lapses, or unaddressed needs—and take proactive steps to close the loop.
Social Determinants of Health: Connect clients with resources such as housing, food security, transportation, and income/benefits support (SSI/SSD, SNAP, HEAP, etc).
Collaborative Care: Work with a network of providers and support agencies to build individualized, person-centered care plans that truly make a difference.
Engagement: Provide face to face outreach, engagement, and service planning in the field including clients' homes, shelters, and hospitals.
Documentation: Maintain documents, records, and other related reports in an organized, timely and accurate manner as per policy and procedure.