Collaborates and communicates with the patient/family, Primary Nurse, Patient Care Coordinator, Physician, Referral Source, and Hospice Interdisciplinary Team to ensure optimal coordination of care for each patient/family and to participate in the development and monitoring of the plan of care to ensure effective patient case management. Recommends/assists the Primary Nurse in coordinating all aspects of care for patients and their families by appropriate communications with various IDT members and referrals to appropriate community agencies/resources as indicated.