The Social Worker for Community Health Initiatives provides professional services to clients and their families eligible for the Healthy Beginnings Services in order to meet identified psychosocial, emotional, financial and environmental needs. This SW will also serve patients/families on board the Mobile Health Clinic performing Social Determinants of Health and providing appropriate referrals/resources. The social worker provides psychosocial assessments, supportive counseling, emergent crisis intervention appropriate to setting, financial resource information, environment enhancements, advance directive planning and referrals to community agencies for clients and their caregivers/families in the client's home, mobile health clinic (MHC), or other settings. Using an interdisciplinary team approach, the social worker ensures clear communication and helps to facilitate care transitions. The social worker identifies and implements interventions at the individual and systemic levels and provides expertise to high risk clients across the continuum. The social worker works collaboratively with the multi-disciplinary team to support the RN performing at the highest level of their license in addition to maximizing the social worker's specialized training to address complex cases. Social Services are provided as part of a collaboration with interdisciplinary teams in adherence to the NFP model, and to policies, procedures, guidelines, and standards of NFP and of the Carle Health System. Involves client/patient/family in case planning decisions. Provides social work intervention to clients and their families eligible for the Healthy Beginnings and/or Mobile Health Clinic services. Helps to facilitate care transitions, referrals to scoial services, and other specialits when needed. Keeps the director/manager informed of problematic cases, especially those involving legal or risk management issues. Provides assistance and advocacy to clients in obtaining financial resources and government entitlements. Develops and maintains tracking system of social services referrals /outcomes. Provides information and counseling for advance directives and health care power of attorney. Provides social work intervention to patient/families eligible for the NFP Program. Responds to referrals from healthcare team members to identify available services for case specific needs. Collaborates with nurse home visitors / supervisors / mobile health clinic staff to meet the needs of high risk populations. Details (direct or incidental) possible to enhance service/care is communicated across service lines and among disciplines. Documents all client interactions, significant observations, interventions, and actions taken in the client's medical record in an appropriate and timely manner. Formulates, develops, and implements a plan utilizing appropriate social work interventions. Provides education and counseling to clients and families around issues related to adaptation to the client's illness and/or life situation. May utilize crisis intervention, brief and long-term individual, group, and family therapies. Assists clients and their families in establishing goals and outcomes through therapeutic relationships by providing education, support, and referral resources. Assesses physical, emotional, social, spiritual, and environmental needs of clients and their families as they relate to the NFP domains. As requested/required, participates in community coalitions and other community organizations in support of NFP as well as promotes public awareness of Healthy Beginnings Services and the Mobile Health Clinic. Facilitates education/training modules to assist RN staff managing basic social work needs.