Care Coordination involves the Social Worker engaging in telephone advice, health advice, the delegation of clinical support activities on behalf of the client, and determination of service needs to increase client strengths and participation in the home, community, and workplace.
The Social Worker may also address structural issues and support treatment requirements. Care Coordination may involve developing, initiating, and coordinating individualized care plans for eligible clients, and providing ongoing resource management and discharge planning as appropriate; conducting alternate planning for non-eligible clients, and providing program interpretation/education to hospital and community agency staff, long term care facilities, physicians, clients, and families.