Primary Responsibilities: Assesses patient and family psychosocial needs and develops plan of care in concert with patient, physicians, nurses, HAs, other members of the departmental team and works in collaboration with other departments/programs such SCC/PAL, CAL AIM, ECM, MOC/SNP, CARE +, regional, SNFs, HIHR, Readmissions, Welcome Wagon, and Psych TOC. Links patients/family to appropriate community resources including but not limited to, information/referral to sources of financial assistance, transportation, support groups, and other community services.