Assisting staff to inform residents and those they designate about the resident’s health status and health care choices and their ramifications; Making referrals and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation); Assisting residents with financial and legal matters; Schedule and conduct discharge planning care conferences; Discharge planning services (e.g., arrangement for alternate placement, intake for home care services, arrangements for DME and other supplies); Identify interventions to support resident’s individual needs through assessment and care planning process; Assist residents to determine how they would like to make decisions about their health care, and whether or not they would like anyone else to be involved in those decisions. Assess residents receiving psychoactive medications, provide appropriate care planning measures including monitoring of side effects, GDRs, behavior monitoring and relevant interventions.