Completes comprehensive psychosocial assessments and reassessments; identifies strengths, preferences, support systems, functional needs, cognitive or behavioral concerns, environmental risks, and barriers to care; and develop individualized social work plans with the sister and interdisciplinary team. Serves as the primary social work resource across the three LWA sites; participates in care conferences, case reviews, team meetings, transition planning; and coordinates medical, psychosocial, spiritual, and practical support with HCPs, RNs, CLCs, house administrators, providers, and leadership.