Conducts assessment and coordinates services to provide assistance and support to clients until their situation is stabilized in their home or other location * service provided to at-risk seniors, persons with physical disability and their care givers, hospital outpatients, newly diagnosed persons * case managers provide counseling and support, system navigation, supportive short term counseling, advocacy, intervention and assistance with coping * care plans are developed with all clients and caregivers to address both practical and personal goals