The Social Services Coordinator works with patients and families to help them access the community resources needed to live a healthy, safe, and independent life by empowering them with tools and resources they need to self-manage their health. The Social Services Coordinator is a member of the Complex Care Team of care managers, behavioral health professionals, and ambulatory pharmacists, and the primary care team of physicians, advance practice providers, RNs, LPNs, MAs, and patient access staff. The social worker also completes thorough assessments of the social determinants of health. Social Services Coordinators focus on self-management support and empowering patients to meet their health care goals. Tasks include: + Assist patients and their families with a multitude of complex services including navigating the health care system and community resources. + Provide support and assist patients and families who require a higher level of care than their current home. + Conducts a social determinants of health screening of all new social work referrals. Social work referrals are received from the complex care team and primary care teams. + Assess patient’s support system, education, employment, current living arrangement, and financial situation/insurance coverage + Review documentation provided by primary care provider to maintain an understanding of current diagnoses. + Assess patient’s current coping strategies. + Review for barriers that may be preventing them from receiving the care they require. + Assist with connecting patient to community resources based on patient’s identified needs + Participate in one huddle weekly with each primary care team to proactively identify patients who may have social determinants of health needs. + Evaluate and help strengthen the patient’s family support system + Provide support and education for patients and families that require or desire additional services to improve health and well-being. + Provide assistance to connect patient and family with resources in the community for families; to decrease burden of caregiver responsibilities, maintain a safe home environment and provide for patient’s home care needs. + Assist with access to the appropriate level of outpatient support + Assist with completing advance directives and POLST forms. + Assist patients with maintaining or obtaining insurance, as well as applying for Patient Assistance and assistance from St. Peter’s Health Foundation. + Assist with the application process for social security disability online. + Assist patients with the screening process by MASH advocate for Medicaid eligibility. + Assist with completing a Medicaid application. + Coordinate in home support services through Medicaid. + Assist with making Medicaid waiver referrals for ongoing community support. + Keep current with changes in community resource availability and/or funding. + Maintains ongoing professional relationships with community agencies. + Encouragement of enjoyment of activities that patients have always enjoyed and assistance with setting goals for the future + Assist patients with self-management support to improve health and overall well-being. + Help patients develop an action plan to achieve goals. + Assist with: + Assisted living facility and skilled nursing facility placement to ensure appropriate level of care. + Home health referrals to local agencies. + Obtaining durable medical equipment. Referral to inpatient and outpatient chemical dependency programs