Coordinates referrals for post hospitalization services/needs: skilled and long-term nursing facilities, assisted living, group homes, homeless shelters, new dialysis, home health, hospice, palliative care, durable medical equipment, infusion services, medication assistance, transportation needs, financial assistance, medical legal partnership, and other community program/services. Completes risk screenings for domestic violence, child abuse, neglect, elder abuse, sexual assault/abuse, institutional abuse, sex trafficking, and notifies applicable state and federal agencies.