- Serve as the primary contact for caregivers, families, support networks, and people living with chronic conditions.
- Conduct biopsychosocial assessments to identify strengths, goals, unmet health-related social needs, and safety concerns.
- Develop personalized care plans aligned with clients’ values and cultural, emotional, and spiritual needs.
- Provide disease- and stage-specific education using the resource library.
- Refer patients and family caregivers to community-based services and supports.
- Coordinate with primary care physicians, healthcare specialists, and the transdisciplinary clinical team to support continuity of care.
- Educate caregivers on burnout, self-care, resiliency, skills training, and support group services.
- Track contact frequency and document interactions, presenting issues, goals, interventions, and action plans.
- Represent Nolia Health at community events and healthcare partner organizations, educating stakeholders and building referral relationships.