Overview

Social workers and case managers coordinate discharge planning resource linkage and psychosocial support to ensure safe transitions and address social determinants of health.

Discharge Planning

Teams arrange home services durable medical equipment and follow up appointments to prevent readmissions and support recovery.

Psychosocial Assessment

Social workers provide counseling crisis intervention and connect patients with community resources for housing food and financial needs.

Care Transitions and Utilization Management

Case managers collaborate with clinical teams and payers to align care plans with patient goals and coverage constraints.