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Patient Resource Specialists (PRS) are responsible for evaluating and maintaining continuity of care as a member of the clinical care team within High Country Community Health’s (HCCH’s) Patient Centered Medical Home model of care. These duties include: new patient orientations, conducting comprehensive assessments of the patient’s health needs (including discovering and discussing potential barriers to adhering to treatment guidelines as well as ensuring patients understand their treatment recommendations/plans), coordinating follow-up outpatient visits at time of hospital discharge, educating patients and clinicians about barriers to health (including BH) improvement/ community resources/insurance benefits/others to assist with informed decision making, representing HCCH at community events such as health fairs, discussing the consumer’s care plan with the client/family/professionals as needed, facilitating communication and coordination among members of the patient’s care teams, involving the patient in decision-making processes, problem solving and exploring options for improving care, assisting patients in safely transferring their care information among settings as needed, advocating for quality care, and encouraging patients to self-advocate for their needs. The PRS develops and maintains working relationships with other community agencies, services, businesses and facilities. Additionally, the PRS will transport consumers to and from HCCH appointments as needed/as available.