referral for Medicaid application, crime victims, etc.); Works with patient's family and friends and enlists their help in his/her discharge planning; Documents completion of patient/family tasks and interaction in medical chart; Assists or arranges for post discharge care to home or facility placement; Assists the patient, families and/or community agencies to resolve barriers to discharge or successful community living; Assists patients in securing required appliance(s) through agencies and rentals; Arranges specific screening, linking planning meetings with family, social agencies, home care agencies, etc. to link patient and to work out a plan of care; Meets with patients and families to offer nursing home/rehabilitation options and transportation options; coordinates or may directly provide transportation; Works as a member of interdisciplinary team and coordinates discharge activities with the overall team, including equipment ordering, arranging linkage and community follow-up; Assesses overall patient-family stability and makes referral to appropriate community agencies for follow-up services; Makes post discharge appoint in collaboration with the patient/family; Participates in Total Quality Improvement activities. TYPICAL WORK ACTIVITIES: Interviews patients, family and friends to gather detailed information covering functional status, fiscal, legal, emotional and relevant personal/family/social strengths and weaknesses; Assesses support network; Collects and revises information on community health and welfare resources; Assesses the value of additional psychological support and counseling for patient and family and makes appropriate referrals; Assesses overall patient-family stability and makes referrals to appropriate community agencies for follow-up services; Provides basic emotional support through understanding patient situation and giving practical guidance and information; Evaluates and refers insurance programs to support discharge plan (e.g.