As part of Giffords Blueprint for Health Spoke Program, this role partners closely with primary care teams, community providers, and social service organizations to deliver comprehensive care management, transitional care support, care coordination, individual and family support, and referrals for housing, transportation, employment, parenting resources, financial supports, and other community supports. The clinician will work collaboratively with patients to develop individualized action plans, support behavior change and recovery goals, provide counseling to reduce harmful or addictive behaviors, and help prevent relapse.