Establishes relationships with existing hospital-based hospice palliative care teams, partner organizations, medical directors, hospital physicians, community physicians, nurses and other team members as well as community members to build a culture of collaboration and clinically integrated care across the continuum. Develops the appropriate treatment plan that maximizes the health potential of the patient (i.e., ordering and interpretation of diagnostic tests, identifying appropriate pharmacologic agents, identifying appropriate non-pharmacologic interventions, developing an education plan as appropriate, interpretation of laboratory and radiology tests, ordering of durable medical equipment).