PATIENT ASSISTANCE - Provide assistance to facilitate patient recovery, discharge and/or management of an acute, chronic or terminal illness or condition; assistance may include education, community referrals, advocacy, and mediation with patients and families to assist in adjustment to changes in health status and functioning expediting timely discharge to an appropriate level of care. * ASSESSMENT - Complete psychosocial assessment of identified patients whose medical status, recovery, or timely discharge may be impeded by inadequate social, environmental, or economic conditions, by inadequate funding sources, and/or by impaired emotional or cognitive status including decisional incapacity.