Assess and advocate for patients by identifying social, emotional, and economic barriers to ensure every individual receives a holistic and dignified care plan. Consult and collaborate with multidisciplinary teams and family members to synchronize treatment goals and ensure a seamless continuum of care. Bridge the gap between clinical care and community support by navigating complex resource networks to secure essential post-discharge services for families. Champion discharge excellence by proactively managing home care and social service transitions, reducing readmission risks and improving patient recovery outcomes. Cultivate strategic partnerships with external health and welfare agencies to create innovative solutions for patients with high-complexity needs.
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Career Level
Mid Level