Complex psycho-social transition planning assessment and reassessment and intervention, Assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, Care coordination, implementation or oversight of implementation of the transition plan, Leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, Communicating with patients and families about the plan of care, Other duties as assigned. The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient's resources and right to self-determination.