Responsibilities: Ensures plan identifies anticipated needs for teaching, parental education/caregiver support, implementation of primary care, evaluation of unresolved medical problems, development of the home care plan, identification and mobilization of surveillance and support services, determination and designation of follow-up care, and details regarding discharge prescription. Ensures case management, social worker and other disciplines have been contacted with identified needs requiring intervention such as post discharge needs, transportation, transfer to another facility, home health, home nutrition needs, etc.