Works with the HealthStart team in identifying patients' psychosocial problems and develop care plans Identifies and addresses barriers to care and navigation challenges across the care continuum y prioritizing health and SDOH needs. Identifies and addresses gaps in internal and external resources, and sustainable connections to medical homes and sustainable social supports to
improve the patient experience and achieve better outcomes Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health
outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed,
including but not limited to social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect,
interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, need for long-term care planning, etc. Care coordination criteria, completes initial intake during enrollment visit, orientates patient to all services and coordinate/monitor delivery of service and
referrals reinforce health education and provide support Participate in performance improvement projects Facilitates the resolution of crucial problems in the individual/family situation relating to recovery or management of the illness or disability through
counseling services to patients and significant persons to the patient's life. Criteria identifies and prioritizes areas for intervention and documents this information. provides related patient and family counseling and referrals
around areas of dysfunction as appropriate. Other tasks as required by manager, director, or leadership.