Works collaboratively with RN Clinical Care Coordinators, physicians, nursing staff, rehab team, pharmacy and lab to facilitate safe transition through acute services with appropriate lengths of stay, with successful discharges to best levels of post-acute care available to the patient. 4. Evaluate each assigned patient, identifies social, emotional, cultural, financial and/or legal issues/problems, formulate and implement an appropriate treatment plan, provides ongoing casework and advocacy services for the patient to ameliorate medically related social or emotional problems.