Also works with pharmacists to resolve medication-related ED visits, such as withdrawal symptoms, medication side effects, or adherence challenges.7.* Provides post-hospitalization support by conducting post-discharge outreach within 24–48 hours to assess social, behavioral, and logistical barriers to recovery, identify patients at high risk for readmission, and ensure they have intensive post-hospital support.8.* Works with each member of the care team to serve as the behavioral health and SDOH expert, ensuring medical, behavioral, and social care are seamlessly integrated.9.* Provides patient education on substance use disorder and mental health concerns and assists clinical teams in evaluating a patient’s need for behavioral health services.10.* Able and willing to travel and meet with patients at practice locations, hospitals, emergency departments, and patient homes within a defined region of care. Conducts outreach to patients with a history of frequent ED visits or inpatient stays, ensuring they have access to primary care, behavioral health support, and community resources.5.* Focuses on crisis prevention and de-escalation by providing early intervention for patients with escalating behavioral health or social crises, ensuring appropriate community-based support is in place, offering same-day or next-day behavioral health support for patients experiencing acute distress, avoiding the need for ED visits, and working with community behavioral health agencies and law enforcement alternatives to divert patients from unnecessary ED use.6.* Collaborates with primary care providers (PCPs), behavioral health specialists, urgent care clinics, and community mental health programs to ensure patients access lower-acuity care settings instead of the ED.