Participates in the development, implementation, and evaluation of the continuum of care: Facilitate patient access, assessing patient needs, ensuring that patients are smoothly transitioned from one care setting to the next, providing information to patients, families, and other providers who are receiving patient, disseminating case management, utilization management activities to appropriate members of the health care team, documenting treatment plan, discharge plan and family/guardian discussions in appropriate place in the medical record. Educates, coordinates, and provides information to members of the multidisciplinary healthcare team who can assist and/or improve discharge planning when knowledge deficit identified; Enhances professional growth and development through participation in educational programs, current literature, in-service education, conferences, seminars, and workshops when needed.