Lead and coordinate timely discharge planning, ensuring clear communication of expectations and next steps with patients, families, and the care team, while proactively addressing logistical needs such as transportation, durable medical equipment (DME), and coordination with business offices, field staff, and external partners to support coordination of care. Provide emotional support and psychosocial interventions to enhance coping, strengthen family systems, and support patients and families through end-of-life care, including education on care options, hiring private caregivers, placement resources, levels of care and more.