- Assessment and Intervention related to social or environmental barriers to care/rehabilitation
- Financial hardships, food insecurity, transportation needs, lodging needs, etc.
- Referrals to and coordination with community partners, agencies, providers (social and medical)
- Entitlement programs, charity organizations, etc.
- Post-discharge follow-up care
- Wrap-around services for patient and family
- Crisis intervention/counseling for caregivers and patients
- Assist with diagnosis/prognosis education and adjustment to illness
- Bereavement and grief support
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- Reports to and coordination with DHR (in cases of Suspected Child Abuse or Neglect)
- Consultation with medical team to discuss and evaluate social concerns
- Any other social, emotional, or environmental needs that may arise during treatment
- Pre-admission planning
- Discharge Planning
- Participate in Medical and Psychosocial Team Meetings, Rounds, Quality Improvement Initiatives, etc.
- Ongoing collaboration with multidisciplinary teams
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