Description JOB SUMMARY This position is responsible for assisting in meeting the patient's needs throughout the continuum of care. Guides patients, families, physicians, and to the appropriate community and adjunct resources that foster quality of life. Interviews patients and families/support systems to obtain an age-specific psychosocial assessment. Assists patients and families in adjustments to illness, disabilities, and resolving difficulties which interfere with the care management process. Provides psychosocial assessments and develops an interdisciplinary plan of care with the patient and stakeholders to best meet the needs of patients and families. Implements/assist with discharge planning services related to the complex patient.