Skills: Case management, Short Term Acute Care Inpatient Medical Social Worker, Care coordination, Discharge Planning, Needs Assessment/ Order DME, Plan of Care, Biopsychosocial assessment, Develop plan of care to meet patient/caregiver needs, Collaborative care, Coordinate services to home care and equipment following discharge, Documents pertinent information to facilitate care coordination, Participates in care conference activities, Refers to rehab and long term care facilities, Refers to other disciplines/resources, Documentation according to plan of care, Provide crisis intervention, AFDC (Aid to Families with Dependent Children), Food stamps, HMOs, Housing Charities, Medicaid, Medicare, Medical Transportation, Medication Assistance, Prior Authorization, Social Security, TANF (Temporary Aid for Needy Families), Agency on Aging, HCBS (Home and Community Based Services), Adult protective services, Child protective services, Suicide/homicide/self-harm, Guardianship, Power of Attorney. An industry-leading on-time start rate and strong relationships with boards of nursing across the country to accelerate the process in all 50 states.