Care Coordination & Transitions of Care Coordinates discharge and transportation needs to post-acute settings (Home, Long-Term Care, Assisted Living, Group Homes, Care Homes, Homeless Shelters, Substance and Behavioral Health facilities and out of state or out of country repatriations) for socially complex cases. If part of the ED Inpatient Care Management Team: Engages with known complex case patients in the ED and collaborates with ED providers, ED social workers and ED case managers to coordinate alternative care placement, wrap around services and community support that often require extended planning and resource navigation.