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. The SWCM collaborates with an interdisciplinary care team to ensure continuity of care and assist patients in accessing services and utilizing resources to support their medical, psychological, and socioeconomic needs.