The case management process focuses on the identification of patients who would benefit from case management services, and the activities of assessment, problem identification, care planning, care delivery, monitoring, and evaluation of the care provided, specifically for its relevance to the needs of the patient/family, and for the health care team's ability to meet the desired outcomes and established goals. The Case Manager manages a designated caseload to coordinate and complete timely assessment, planning, implementation and evaluation of discharge plans and care transitions across the continuum of care.