CM will consult CCC team member for the discharge planning needs of patients who are on palliative care, patient's that are substance abusers, homeless and uninsured, patients, victims of domestic violence, elder abuse, and child abuse, patients who need referrals for inpatient and outpatient terminal care, inpatient, outpatient psychiatric care, Subabcute and Acute Rehab placements, Home Visiting Nurse services and patients living in assisted living facilities, group homes and adult homes. Utilizes interview skills to determine:Patient's discharge planning goalsFamily's discharge planning goalsNeed for institutional and/or specialized careMulti-disciplinary teams goals for patient including (primary care physician, primary care nurse, continuing care coordinator, physical therapist, visiting nurse, speech pathologist, dietician)Incorporates a,b,c,d, into an appropriate discharge plan for the patient.