ESSENTIAL FUNCTIONS: Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation to assesses, documents, and addresses psychosocial, cultural, emotional, and economic needs of patients and families during the hospitalization and discharge planning process. Collaborates with the multidisciplinary team, outpatient care team, and community partners as needed, to assist with length of stay, patient throughput initiatives and creatively resolve issues that could prevent safe and timely patient discharges.