Collaborate with the medical providers and patients to develop, implement, and coordinate Health Homes compliant care plans for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health conditions, substance use, and more and document care plan outcomes. Provide direct service to a caseload of chronically ill patients and help them achieve their care plan goals by facilitating referrals, addressing access issues, connecting them to local resources, and developing relationships with healthcare providers.