In collaboration with the Care Transitions team, provides patient and family advocacy and psychosocial interventions for patients referred to the care transition program. Strives to promote patient and family wellness, improved care outcomes, completion of advance care planning, and access to post-acute physician services, ordered hospital and/or out-patient services and appropriate community resources. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. ESSENTIAL FUNCTIONS: Systematically gathers pertinent psychosocial data for patients referred to the care transition program whereby patient and family psychosocial needs can be identified and appropriate interventions performed. Activities include, conducting home visits to perform a psychosocial assessment for the patient and family, incorporating social, cultural/ethnic, emotional and spiritual aspects of care. Accessing patient's prior medical record and collaborating with Hutchinson Regional Medical Center care management department staff as a resource for assessment and decision making. Participate in interdisciplinary and inter-agency collaborative efforts to identify and modify post-acute care needs Develops psychosocial plan of intervention utilizing all available sources of information. Activities include developing a focused plan of intervention based upon the psychosocial assessment in collaboration with the interdisciplinary team when appropriate and based upon the patient identified needs. Incorporates social, emotional and spiritual aspects of care into the patient's plan. Acknowledges the impact of cultural values and beliefs, including views on illness, disability, and death and incorporates into the assessment and plan of intervention. Creates plans and strategizes with the health care team, to minimize frequency of hospital admissions and/or emergency department visits. Collaborates with the Care transition team and Hutchinson Regional Medical Center Care Management staff, and care providers to ensure that all appropriate services and resources are utilized in a timely and efficient manner. Activities include addressing psychosocial and financial barriers that may impede progress throughout the patient care continuum or interfere with medical compliance. Responds to suspected violence, assault, abuse and/or neglect cases in accordance with social work professional ethics. Facilitates advance care planning. Activities include addressing end of life issues, healthcare proxies, living wills, advance directives, and power of attorney. Stays abreast of changing care management and Social Work clinical trends, regulatory matters and payer requirements Uses pertinent performance metrics to drive improvements in practice that will enhance patient or consumer safety, satisfaction, efficient and effective care and that will identify and promote best practices and equitable care on a multidisciplinary basis. Completes timely and accurate documentation as per agency policy. Abides by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI). Establishes and maintains positive working relationships with patients, family members, co-workers, physicians and referral sources.