Identify and remove barriers to the discharge/transition process by: Identifying complex discharge/transition needs early on in order to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc. Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc.