Provides direct patient care that may include: case management, care coordination, interdisciplinary collaboration for care transition needs, crisis intervention/safety planning, counseling, and emotional support to patients and families coping with illness, trauma, or end-of-life care, referral and discharge planning. Provides education to patient/family with respect to meeting established goals including but not limited to disease prevention, impact of illness and disease progression, advocacy for benefits, health maintenance, and adherence to treatment regimens.