Complete assessment of all patients referred or identified as having complex psychosocial concerns and/or as needing discharge planning services, including data related to home environment, support systems, community agency involvement and psychosocial concerns to determine post-hospital/clinic visit needs. Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other SPH departments, external service organizations, agencies, healthcare facilities and providing resources to patients as needed.