RN Case Manager St. Croix Hospice LLCRN Case ManagerLombard, IL$85,000–$97,000 / yearIf you are ready to be part of our deeply compassionate family of caregivers guiding extraordinary life experiences, then we invite you to join our team, where your work truly matters. An employee's actual annual salary will be based on but not limited to: geographic location, relevant education, applicable certifications, depth of experience, and special skillsets.
Case Manager Full Time and PRN AHS Vista LLCCase Manager Full Time and PRNWaukegan, ILThis role plays a crucial part in ensuring patients receive the best possible care by coordinating services, facilitating discharge planning, and optimizing the care continuum. Provide education to patients, families, physicians, and the multidisciplinary team on case management processes, insurance approvals/denials, and available healthcare resources.
NewSUBSTANCE USE CASE MANAGER Sinai Health System IncSUBSTANCE USE CASE MANAGERChicago, ILAlong with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Ensures all healthcare providers involved are current with case information and collaborates with patients' families, friends, and caretakers to effectively share information.
NewOpioid Remediation Case Manager DeKalb County, IllinoisOpioid Remediation Case ManagerSycamore, ILFull timeWhat You'll DoAssess participant needs and build personalized care plansConnect clients to housing, healthcare, financial assistance, and other community resourcesCollaborate with healthcare providers, counselors, probation, and the Treatment Courts teamMonitor client progress and adherence to case plansProvide crisis intervention and support during emergenciesEducate clients and families on available servicesAttend court sessions, staffings, and meetings as part of the treatment teamWhat You BringExperience in social work, case management, or a related field preferredStrong written and verbal communication skillsSound judgment and problem-solving abilityCultural sensitivity and the ability to connect with a diverse caseloadWorking knowledge of community social service agenciesStrong organizational and time-management skillsProficiency in Word and ExcelA valid driver's license (required for client transport)Bilingual English/Spanish skills a plusGood to KnowThis position reports to the Treatment Courts Supervisor and DirectorEmployment is contingent upon a clear criminal background check and a TB screening testSome local travel required using a Treatment Courts vehicleThis position is grant-funded through 6/30/27, with renewal anticipated annually In this role, you'll be a critical link between Treatment Court participants and the resources they need to rebuild their lives - connecting clients to healthcare, housing, counseling, and community support while helping them stay on track with their treatment and recovery plans.
Residential Services Manager YWCA Evanston/North ShoreResidential Services ManagerEvanston, IL$51,555–$57,283 / yearEnsures Residential and Crisis Support Specialist staff maintain continuous, on-site availability during scheduled Crisis Line shifts in accordance with agency protocols, including adherence to step-away, communication, and supervisory approval requirements to ensure uninterrupted coverage and timely response. Creates and maintains scheduling and staffing of the 24-Hour Crisis Line and ensures staff are fully trained, engaging with callers in accordance with agency protocol, and regularly coordinates with the domestic violence team to ensure smooth operation of the 24-Hour Crisis Line.
Housing Case Manager - Bilingual Spanish Inspiration CorporationHousing Case Manager - Bilingual SpanishChicago, ILFull timeHousing Case Managers will be assigned to serve any/or all of the following populations based on program need : individuals, families, domestic violence survivors, victims of dating violence and stalking, individuals with serious mental illness, substance use disorders, chronic health conditions, physical and mental illness and impairment, criminal justice-involvement, DCFS involvement etc. This includes, maintaining regular monthly contact with all assigned participants and their landlords, supporting program participants as needed to ensure they do not return to homelessness, and meeting and/or exceeding programmatic goals defined internally and by funders.
Personal Injury Case Manager The United FirmPersonal Injury Case ManagerChicago, IllinoisAt The United Firm | La Liga Defensora, APC, our expert legal team is a driving force behind our continued success. Manage attorneys' schedules efficiently, including client meetings, court appearances, and other appointments.
Fertility Nurse Case Manager US FertilityFertility Nurse Case ManagerVernon Hills, Illinois$72,000–$84,000 / yearWhether collaborating with more than 200 highly respected physicians nationwide or partnering with colleagues who are passionate about solving meaningful problems, you’ll be surrounded by a team committed to shared success. Our team members choose to build their career home at US Fertility because of the hope we inspire in our patients , the lives we help bring into the world , and the culture of excellence we foster across our organization.
Fertility Registered Nurse Case Manager Per Diem Fertility Experience Required US FertilityFertility Registered Nurse Case Manager Per Diem Fertility Experience RequiredHoffman Estates, IllinoisWhether collaborating with more than 200 highly respected physicians nationwide or partnering with colleagues who are passionate about solving meaningful problems, you’ll be surrounded by a team committed to shared success. Our team members choose to build their career home at US Fertility because of the hope we inspire in our patients , the lives we help bring into the world , and the culture of excellence we foster across our organization .
Fertility Nurse Case Manager ( Bilingual in Spanish Preferred) US FertilityFertility Nurse Case Manager ( Bilingual in Spanish Preferred)Chicago, IllinoisWhether collaborating with more than 200 highly respected physicians nationwide or partnering with colleagues who are passionate about solving meaningful problems, you’ll be surrounded by a team committed to shared success. Our team members choose to build their career home at US Fertility because of the hope we inspire in our patients , the lives we help bring into the world , and the culture of excellence we foster across our organization.
Case Manager Integrated Resources, IncCase ManagerDowners Grove, IllinoisContractorEssential functions:Evaluation of members: Through the use of care management tools and information/data review, conductsEnhancement of medical appropriateness and quality of care: Using holistic approach consults with case managers,Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/orUtilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/Provides coaching, information and support to empower the member to make ongoing independent medical and/orHelps member actively and knowledgably participate with their provider in healthcare decision-making. Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
Case Manager, Registered Nurse Field (Bureau County, IL) CVS HealthCase Manager, Registered Nurse Field (Bureau County, IL)Chicago, IllinoisWith compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences.
Case Manager - Registered Nurse CVS Health CorpCase Manager - Registered NurseWork At Home-Illinois, IL$66,575–$142,576 / yearWith compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Collaborates with supervisor and other key stakeholders in the member's healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences.
Personal Injury Case Manager The United Firm | La Liga Defensora, APCPersonal Injury Case ManagerChicago, ILAt The United Firm | La Liga Defensora, APC, our expert legal team is a driving force behind our continued success. Manage attorneys' schedules efficiently, including client meetings, court appearances, and other appointments.
Medical Field Case Manager Genex Service LLCMedical Field Case ManagerOak Lawn, ILUse advanced knowledge of types of injury, medications, comorbidities, treatment options, treatment alternatives, and. human compassion to help people recover after workplace injuries or auto.
Hospice RN Case Manager (South Suburbs) Advocate Aurora Health IncHospice RN Case Manager (South Suburbs)Oak Brook, IL$38.20–$57.30 / hourMust demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise.
Physical Therapist (PT) - Home Health Case Manager - Advocate Aurora Health IncPhysical Therapist (PT) - Home Health Case Manager -Oak Lawn, IL$44.15–$66.25 / hourAdvocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development, and so much more - so you can live fully at and away from work, including: Compensation: Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise.
Case Manager Care Coordination Full Time Days Northwestern Memorial HealthCareCase Manager Care Coordination Full Time DaysWinfield, ILPartners with the nursing staff and physicians to convey accurate and timely information to post-acute care providers to encourage a smooth hand-off and create a seamless and safe discharge to the next continuum of care. Ensures that the interdisciplinary care plan and the discharge plan are comprehensive and consistent with the patient's clinical course, continuing care needs, and coordinated with covered services as available.
Case Manager, Registered Nurse (Field Mt. Prospect, IL and surrounding areas) CVS Health CorpCase Manager, Registered Nurse (Field Mt. Prospect, IL and surrounding areas)Chicago, IL$66,575–$142,576 / yearThe Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs.
Case Manager, Registered Nurse - Field (Iroquois/Kankakee, IL) CVS Health CorpCase Manager, Registered Nurse - Field (Iroquois/Kankakee, IL)IL$66,575–$142,576 / yearThe Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs.
NewHome Health RN Case Manager-Part Time Des Plaines, Mount Prospect, Arlington Heights, Wheeling, areas Advocate Health and Hospitals CorporationHome Health RN Case Manager-Part Time Des Plaines, Mount Prospect, Arlington Heights, Wheeling, areasDes Plaines, Illinois$38.20–$57.30 / hourFlexible part time position working 3 days per week, 8-5 schedule, weekend rotation with flexible schedule; on call schedule based on staffing needs typically 2-3 times a month, holiday schedule 1 winter and 1 summer holiday; Work/life balance, mileage reimbursement, opportunity for incentive pay, great culture and team collaboration. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise.
Clinical Therapist - Behavioral Health Clinician Friend Family Health CenterClinical Therapist - Behavioral Health ClinicianChicago, IllinoisThis role supports individuals experiencing a wide range of mental health conditions and may operate across multiple service lines, including outpatient therapy, crisis assessment and intervention, and specialized programming (e.g., Applied Behavior Analysis), depending on program assignment. The Behavioral Health Clinician is a Master’s-level licensed or license-eligible therapist responsible for providing comprehensive mental health services, including assessment, diagnosis, treatment planning, and evidence-based therapeutic interventions.
Clinical Therapist - Behavioral Health Clinician Human Resources Development IncClinical Therapist - Behavioral Health ClinicianChicago, ILPart timeThis role supports individuals experiencing a wide range of mental health conditions and may operate across multiple service lines, including outpatient therapy, crisis assessment and intervention, and specialized programming (e.g., Applied Behavior Analysis), depending on program assignment. The Behavioral Health Clinician is a Master’s-level licensed or license-eligible therapist responsible for providing comprehensive mental health services, including assessment, diagnosis, treatment planning, and evidence-based therapeutic interventions.
CVI Case Manager (Chicago) Public Equity LlcCVI Case Manager (Chicago)Chicago, ILFull timePublic Equity is seeking dedicated and compassionate Community Violence Intervention (CVI) Case Managers to support individuals and families impacted by community violence throughout the Englewood, Chatham, and Auburn Gresham communities. Case Managers will work closely with outreach teams, community partners, hospitals, schools, and social service agencies to ensure participants receive comprehensive support services tailored to their individual needs.
Case Manager Youth Engagement Goodwill Industries Of Southeastern Wisconsin IncCase Manager Youth EngagementChicago, ILThe Case Manager provides support and resources to individuals in need of support to the underserved population and address barriers to employment to include transportation, soft and hard skills development, access to critical resources such as housing and healthcare, and other social, cultural, and environmental conditions that impact the individual's life. RESPONSIBILITY LEVEL: Assume primary responsibility for providing pre- and post-employment case management services, social services navigation, coaching, and other supportive services to youth ages 16 - 24 within Metro Chicago.
Registered Nurse Case Manager Chicago MetroRegistered Nurse Case ManagerChicago, Illinois$50–$70 / hourAs a member of our team, you’ll play a key role in providing quality home healthcare, where patients are able to remain independent at their place of residence in the healthiest and happiest state of being possible. Inspired by nurses, Boost Home Healthcare makes it easier for patients to focus on recovery and wellness by personalizing and coordinating care.
NewRegistered Nurse Case Manager, Inpatient Trinity Health CorporationRegistered Nurse Case Manager, InpatientMaywood, IL$35.89–$62.91 / hourCARE COORDINATION: The Inpatient RN Care Manager works with the multidisciplinary team including physicians, staff, and payers to ensure patient's progress along the continuum of care in an efficient and cost effective manner that ensures quality outcomes. Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
NewRegistered Nurse Case Manager, Inpatient Part Time Trinity Health CorporationRegistered Nurse Case Manager, Inpatient Part TimeMaywood, IL$35.89–$62.91 / hourCARE COORDINATION: The Inpatient RN Care Manager works with the multidisciplinary team including physicians, staff, and payers to ensure patient's progress along the continuum of care in an efficient and cost effective manner that ensures quality outcomes. Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
Fertility Nurse Case Manager Simple StaffingFertility Nurse Case ManagerRolling Meadows, ILWhether collaborating with more than 200 highly respected physicians nationwide or partnering with colleagues who are passionate about solving meaningful problems, you’ll be surrounded by a team committed to shared success. In this role, the Fertility Nurse Case Manager will: Assist with the coordination, case management, and treatment of fertility patients.
Workforce Development and Jericho Education Fund Case Manager Inspiration CorporationWorkforce Development and Jericho Education Fund Case ManagerCHICAGO, ILFull timeThe Workforce Development and Jericho Education Fund Case Manager supports participants in meeting their employment, career pathways and educational goals by providing case management, supportive services, and career counseling to participants considering or enrolledin InspirationKitchens foodservice training program or receiving education and training tuition support from the Lori & Ron Jericho Memorial Education Fund. Support participants in entering and completing the food service training program and Jericho Education Fund and in meeting their education and/or training, employment placement and job retention goals, using trauma-informed, strengths-based, low-barrier, harm-reduction approaches.
Case Manager The Salvation Army USACase ManagerChicago, IL$17.05–$20.40 / hourCase plan may include but is not limited to the following focus areas: budgeting, housing, the need for medical, mental health, substance abuse intervention, special needs of children, problem solving, family life, child safety, vocational training, job opportunities, education and/or domestic violence services. Ability to assess the needs of the homeless, utilize effective case management strategies to engage participants, foster cooperative working relationships with clients, empower clients to meet case plan goals, and implement case management practices to achieve agency goals and objectives.
Hospice RN Case Manager Journeycare IncHospice RN Case ManagerPalos Heights, ILWe prioritize manageable caseloads, strong interdisciplinary support, and giving our nurses the time they need to truly care for patients and families. We are seeking a compassionate and experienced Hospice RN Case Manager to provide patient-centered, end-of-life care in the Homewood area.
Territory Manager of Healthcare Partnerships - IL, IN, KY, WI Territory Mom's MealsTerritory Manager of Healthcare Partnerships - IL, IN, KY, WI TerritoryChicago, ILFull timeEffectively present Mom’s Meals products and services to a variety of audiences including managed care organizations as well as case managers, social workers, physicians, nurses and dietitians. Consistently utilize company programs and systems to maximize and prioritize each of the qualified Tier account engagements and create efficient weekly sales routes to meet scheduled meetings, drop-ins, and client educational opportunities.
Case Manager RN Supervisor - Remote Metro Chicago Optech, LLCCase Manager RN Supervisor - Remote Metro ChicagoDowners Grove, ILRemoteAbility to skillfully manage multiple, complex projects and competing priorities while working under pressure to meet deadlines and maintaining strong customer service orientation. The Case Management Supervisor is responsible for directing the operations of their designated department, which may include one or more of the following functions: human resources and customer service.
Case Manager La Casa NorteCase ManagerChicago, IllinoisOur programs, including Casa Corazón (Drop-In and Emergency Beds) and Solid Ground Supportive Housing, aim to transform the lives of homeless and at-risk youth (ages 16–24) by providing them with the stability, support, and guidance they need to thrive. Title: Case Manager Reports To: Youth Development Manager Salary Range: $41,212 – $44,302 annually Schedule: Tues-Fri 10 am – 7pm & Sat 9 am – 6pm Classification: Full Time - Exempt La Casa Norte’s mission is to serve youth and families confronting homelessness.
NewSafe@Home Case Manager - Cook County OMNI For AllSafe@Home Case Manager - Cook CountyBuffalo Grove, IllinoisSAFE@Home Safety Services are meant to provide reasonable efforts to preserve families to enable children to remain safely at home, avoid separation and placement of the children, and facilitate timely reunification. Work collaboratively with the IFS Case Manager to connect families to needed services and interventions, Work collaboratively with the service providers to connect families to needed services and interventions.
Case Manager LSW or RN or LPN Clermont Senior ServicesCase Manager LSW or RN or LPNBatavia, IllinoisTwo years experience in community-based programs with knowledge of community resources, available funding sources, the aging process, health and social service intervention techniques, Must meet the Agency’s general requirements. Identifying the customer’s care needs in the areas of physical, cognitive, social and emotional functioning as well as financial and environmental needs and identifying formal and informal support systems.
Interim Onsite Case Manager Jtec Industries IncInterim Onsite Case ManagerChicago, ILThis position is responsible for providing direct clinical and case management services, including: intake and assessment with new tenants, collaborative development of individual service plans with tenants, crisis intervention, individual counseling and providing therapeutic group activities to help tenants meet their goals. Case managers assist tenants in goal attainment, including but not limited to: maintaining their housing, obtaining and maintaining sustainable income, and achieving health and wellness goals.
NewRegistered Nurse Case Manager, Inpatient Trinity HealthRegistered Nurse Case Manager, InpatientMaywood, Illinois$35.89–$62.91 / hourCARE COORDINATION : The Inpatient RN Care Manager works with the multidisciplinary team including physicians, staff, and payers to ensure patient's progress along the continuum of care in an efficient and cost effective manner that ensures quality outcomes. Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
NewRegistered Nurse Case Manager, Inpatient Part Time Trinity HealthRegistered Nurse Case Manager, Inpatient Part TimeMaywood, IL$35.89–$62.91 / hourCARE COORDINATION: The Inpatient RN Care Manager works with the multidisciplinary team including physicians, staff, and payers to ensure patient's progress along the continuum of care in an efficient and cost effective manner that ensures quality outcomes. Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
Violence Prevention Case Manager National Youth Advocate ProgramViolence Prevention Case ManagerChicago, ILThe Case Manager works to make a meaningful difference in the lives of the children being served by the National Youth Advocate Program by working closely with the youth and family to provide advocacy and support towards targeted goals. Assess immediate crisis needs and long term needs of participants and address appropriately by providing services and service referrals ensuring stability.
Hospice RN Case Manager Laws & AssociatesHospice RN Case ManagerNorthbrook, IllinoisAs a Hospice RN Case Manager, you'll manage and coordinate care for patients in a home-based setting, working closely with an interdisciplinary team to ensure comfort, dignity, and quality of life. This opportunity is with a well-established hospice team in the North Suburbs of Chicago that is focused on creating a more sustainable and supportive environment for nurses doing this important work.
Tax - Manager, Legal Business Services - Technology Deloitte Touche Tohmatsu LtdTax - Manager, Legal Business Services - TechnologyChicago, IL$134,475–$274,750 / yearTTC's business services help clients with operating model evaluation, roadmap development for a desired future state, data management solutions, automation opportunities, tax portal, cloud for enterprise systems, agile resourcing models, risk, provision and compliance. At Deloitte Tax LLP, our Tax Technology Consulting (TTC) practice helps tax departments pursue a streamlined, transparent, and efficient tax function that enhances the core responsibilities of compliance, reporting and planning, while also positioning tax as a strategic business advisor for the digital era.
Tax Manager, Legal Entity Management Deloitte Touche Tohmatsu LtdTax Manager, Legal Entity ManagementChicago, IL$144,600–$274,750 / yearAt Deloitte Tax LLP, our TTC practice helps tax and legal departments pursue a streamlined, transparent, and efficient tax and legal functions that enhance the core responsibilities of compliance, reporting and planning, while also positioning tax and legal as a strategic business advisor for the digital era. As a Manager in Legal Entity Management, your focus will be enabling our clients annual governance process with an emphasis on United States compliance, you will also support the review of governance structures, assessments of corporate documents and management of corporate data.
Mental Health Counselor Lead - 2025800 World ReliefMental Health Counselor Lead - 2025800Chicago, ILHybrid Work Schedule: 1 day onsite and 4 work from home days} ROLE & RESPONSIBILITIES: This role is responsible for supervising others and includes responsibilities consistent with supervising employees, including but not limited to monitoring daily work activities, tracking and approving timesheets including approving time off, monitoring performance including entering goals, progress check-ins, and weekly or bi-weekly check-ins, documenting performance concerns, entering staff promotions, transitions, and separations in HRIS within required time frame. Managers at World Relief are also considered spiritual leaders and are expected to lead staff in a manner consistent with our Christian values, including but not limited to praying with staff, leading devotionals, and fostering a Christian environment in interactions with staff throughout World Relief.
NewRN Case Manager Moments HospiceRN Case ManagerWillowbrook, California$75,000–$90,000 / yearJob Type: On The Road #RegisteredNurse #RN #CaseManager #Nurse #RNCaseManager We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. As an RN Case Manager, you will play a critical role in making our patients' final days, weeks, and months as comfortable as possible.
School Case Manager PEL/LBS1 HealthPRO HeritageSchool Case Manager PEL/LBS1Chicago, ILObtain IEPs and special education files for newly enrolled students, and coordinate services for new students. Meet regularly with School Principal and Director of Specialized Services to collaborate, communicate, and continuously improve the special education program.
Social Work Case Manager Sales MatchSocial Work Case ManagerChicago, IllinoisThis role involves helping clients navigate social services, healthcare, and personal challenges, developing care plans, advocating for client needs, and ensuring the coordination of services. We are hiring a Social Work Case Manager to provide essential case management services to individuals and families in need.
Medical Case Manager CchcMedical Case ManagerChicago, IllinoisBachelors Degree in social services, public health, health administration, human services field or an Associates degree with appropriate certifications (i.e., CADC, LPN) with at least three (3) years experience in social services (case management experience preferred). The Medical Case Manager assists individuals living with HIV in accessing and adhering to health care services linking them with core clinical, psychosocial and other related services.
Correctional Case Manager Safer FoundationCorrectional Case ManagerChicago, IllinoisHands-on experience and self-sufficiency with Microsoft productivity tools, including Outlook (for email), Office (Word, PowerPoint, Excel) and online collaboration tools (video conferencing, Zoom/Teams, messaging). Work one-on-one with residents to address issues that arise that threaten employability and overall well-being, including barriers to transition into the community and refer to appropriate services as needed.