Specifications include, but are not limited to: • facilitate skills training and outings, both in the hospital and in the community • support community reintegration activities • assist clients in developing life goals and use person directed planning approaches • serve as an advocate for the client as needed • act as a liaison between the client, IDT’s, social support network, and community providers • participate as an active member of IDT • consultation with IDT’s and community providers • maintain patient caseload • documentation and discharge recommendations • establish and strengthen community ties to promote quality of life and long term maintenance in the community • provide follow up services 30-days post community transition • coordinates on-going care and supports transition to the community.