Raven Matthews

- Assesses, evaluates, plans and coordinates community services
- Advocates for services to meet the specific patients / family complex needs

- Conducts high risk/biopsychosocial assessments within timeline required by departmental and regulatory guidelines
- Provides patients / family members with Community Resources
- Coordinates the transition to post-acute care services (Hospice, Home Health, Skilled Nursing
Facility, etc.)

- Organizes family meetings and/ team conferences
- Collaborate with the treatment team to provide solutions for complex cases (i.e. Behavioral Health and/or
barriers to discharge)
- Identifies high risk patients based on standardized criteria
- Coordinates appropriate reporting to legal agencies as needed with respect to abuse and neglect
- Identifies and documents quality variances and/or barriers to discharge