Job Summary: Provides a wide range of clinical social work services in a primary care or home health setting, including support and consultation to care team in managing patients. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest level of independence. Coordinates with others to establish a plan of care. Provides short term counseling, teaching and brokering with other resources for care giving needs. Essential Responsibilities: • Provide appropriate social work interventions to all age patients and their families including but not limited to psychosocial assessment, brief individual or family, advocacy, linkage, referral, group work, case coordination, and long-term care planning and placement. • Consultation and coordination with multidisciplinary team of care professionals and primary care site medical/nursery staff, to include family conferences, care conferences, team meetings etc. • Assesses patient and family needs for care and communicates with other health care providers appropriately. Collects data relevant to visit with ongoing assessment throughout the duration of care. Evaluate psychosocial assets and deficits for the purpose of enabling the pt to maintain the greatest level of independence. • Evaluates patients/family needs through timely assessment, communication and observation. Modifies plan of care through assessment based upon patient/care systems response.