Engage people face-to-face and/or telephonically to complete a comprehensive needs assessment or wellness assessment (as appropriate), including assessment of medical, behavioral, functional, cultural, and social drivers of health (SDoH) Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person's readiness to change to support the best health and quality of life outcomes by meeting them where they are in their health journey. Provide referral and linkage as appropriate and accepted by the individual being served (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.).