Tasks may include completing a SPOA application or other housing made available, prepping for interviews, follow up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood; Participate in hospital discharge planning meetings to identify the best community resources for returning participants; Provide short term therapeutic counseling and support to participants pre and post housing; Supervise case managers and peers on the SOS team; Collects and reports data, as required and work with team leader, data analyst and other SOS teams to use data to inform future care delivery; Once housed work with participants and their housing providers to resolve clinical issues that are impacting on the participant’s ability to manage, and retain supportive housing; Foster relationship with community providers to ensure that recipients are connected with appropriate services as they transition back into the community; Appointment navigation including accompaniment to appointments, travel training, reengagement in community care, and addressing barriers to care; Facilitating crisis interventions, referrals, and hospitalizations as appropriate. Persistent and assertive outreach and engagement using strength-based approaches beginning either at known “hang-outs” or “hot spots” within the homeless services system or during an inpatient hospital admission or emergency department visit; Partnering and collaborating with current street outreach teams, local police departments, local hospitals, the NFTA, the Homeless alliance of Western NY and family members/caregivers to identify those in most need of outreach and care; Continuously assess the health and social needs of participants through SOS’s conversational and observational assessments and formalized risk assessments tools for those identified as being at high risk; Work in collaboration with the established referral Hub to identify available housing and to support participants through the process.