Recognize and educate staff that managing patient care is a team effort that involves clinical and nonclinical staff (e.g., physicians, nurse practitioners, physician assistants, nurses, medical assistants, educators, front desk staff, schedulers, etc.) interacting with patients to achieve stated objectives. The person in this role will act as a charge nurse for the Patient Care Team to identify barriers to care and to understand the interplay between physical health, mental health, social issues and resource needs, and will encourage patients and their families to actively engage in their own health and work toward maintenance or improvement of health status.