Job Function:

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations; to assist them with personal and environmental challenges,
• Educate participants and their authorized representatives in understanding and using community, health and public services and benefits which help them remain safely in the community
• Ensure timely and appropriate communication and coordination of care during/post hospitalization, or other inpatient stay, to ensure that a participant's wishes regarding his/her care are followed during that admission.
• Ensure telephonic outreach is made within 24-48 hours of hospitalization, and regularly thereafter during admission, to provide support to the participant, to coordinate with the hospital clinical team to discuss participant's treatment plan, and to assist in discharge plan coordination.