Helps individuals with serious and complex health care challenges to navigate large health care systems and find the resources they need. Improves coordination of medical and social services needs such as long-term care, mental health, medical specialists, and housing. Assists with such activities as: transition planning when leaving a hospital or care facility; referral to community and social supports, such as transportation and food resources; and coordinating better communication between your medical providers, family, and other caregivers.