Identifies and facilitates appropriate referrals to alcohol and drug programs, disability services, employment & training programs, mental health providers, housing services, family resources transportation, long-term care planning, social services, resources for food and financial security, county, state, and federal programs, and other community sources of support based on patient need. Enables consultation with interdisciplinary providers such as psychiatry, medication assisted treatment, intensive outpatient nurse case management and other embedded programs as needed.