Job Description

Participates in the development of the plan of care in conjunction with the interdisciplinary team.

Completes initial and follow-up assessments on participants when significant changes in condition occur. 

Maintains contact with community support groups and provides professional expertise as required. Assesses the need for, and makes arrangements for, alternative community services, use of volunteers, and the referral to other disciplines or services.

Prepares clinical and progress notes and documents all patient/family services provided.

Assists physician and other team members in understanding the significant social and emotional factors related to health problems.

Provides ongoing information, emotional support and counseling to participants and their families with needs related to social supports, financial support or counseling, housing appropriateness, psychological supports, and initiates and completes plan to resolve problems and conflicts.