Serves in an expanded role to collaborate with patients, Palliative Care Providers, practice teams, all community agencies, including, but not limited to, behavioral health, housing authorities, Department of Health and Human Services, transportation and home health organizations, and other medical/specialty services to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Performs social work activities, as set forth herein, in a variety of settings, including, but not limited to PCP offices, patient homes, hospital, or other community based settings as deemed appropriate for each individual high risk or complex patient in collaboration with Care Coordinator, contracted home health agency or primary care provider and all other service and health providers who the patient is working with.