PRIMARY FUNCTION: To assist patients and families to identify social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of discharge planning and social work services. PRINCIPAL DUTIES AND RESPONSIBILITIES: Works with the patient, family, and other members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the needs identified. Determin