Service Coordination, Navigation and Direct Service Skills: Connect patients to primary care medical homes, including assistance with follow-up appointments and care coordination between inpatient and outpatient teams, both medical and social work/case management. Work directly with CATCHH (CHWs Addressing Transitions of Care for Hospitalized unhoused patients) program, which focuses on hospitalized houseless patients nearing, and post-, discharge in effort to improve transitions of care.Capacity Building and Advocacy Skills: Engage patients and family in discharge planning, health promotion, and health education. Support and provide general health related education and counseling, especially in unhoused patients. Promote individual and collective empowerment through health education, skill development, advocacy, organizing and collaboration with strategic partners.Education and Facilitation Skills: Use learner-centered teaching to provide one-on-one education on wellness and disease management and encourage patients to adopt self-management skills. Schedule and/or deliver health education classes in designated communities.?Individual and Community Assessment Skills; Outreach, Evaluation and Research Skills: Conduct outreach to houseless individuals, who have recently been discharged from an inpatient setting, with high level of medical complexity. Provide assessment and documentation of patients health-related social needs and assets; participate in family and community assessments. Coordinate with team members across various project requirements. Assist with developing assessment and evaluation tools for project longevity and maximum positive patient outcomes. Will also be responsible for documentation of patient needs, resources connected to, encounters, and follow-ups using software tools adapted with the University and care teams. As this documentation will be used for program evaluation and assessment, accuracy and timeliness will be critical.Communication and Organizing Skills: Coordinate with community partners, serve as liaison between Dell Medical School, Dell Seton Medical Center, UTHA, CommUnityCare, Lone Star Circle of Care, and other community partners, utilize written and verbal communication, and assist with building a foundation for long term solutions. Work closely with above partners to improve the local health care systems ability to serve houseless patients during transitions of care.Other related duties as assigned.