as depression and anxiety; Case management/care coordination, particularly for individuals with chronic and/or complex medical conditions; Patient navigation, especially for patients moving among different health care levels (e.g., inpatient, outpatient, home health, or long-term care); Counseling on adjustment to chronic disease, life planning and end-of-life issues; Identification and referral for specialized services, such as drug and alcohol treatment, legal services, financial and employment counseling, and housing support; Education and support programming (e.g., diabetes education, parenting classes, domestic violence support programs) for individual and groups; Assistance with entitlements, medications, transportation, and advance directives; Assessment and intervention in domestic violence and child abuse situations; Outreach and coordination with other community resources and agencies; and Community-level advocacy on behalf of patients and families. Works collaboratively with the multidisciplinary healthcare team to include the primary care physician, specialists, nurse case manager, community health worker, pharmacist, to coordinate care for patients/families presenting with social, financial or biopsychosocial needs.