Providing tailored interventions for a wide range of psychosocial issues to include, housing/homelessness, food, finances, family/caregiver support, home care/placements, legal, education, employment, disability, mental health/addiction, medical and reporting of abuse/neglect. Assist with long term care placement, discharge planning, hand off communication and transitions between levels of care and arranging for in home services to ensure care is timely and appropriate.