This role assesses home care needs, educates patients and caregivers on safe and effective home health and hospice services and infusion devices, and partners closely with interdisciplinary teams, referral sources, and community providers to ensure seamless, high-quality transitions of care. 1. Utilize comprehensive assessment skills to determine a patient’s appropriateness for home care, initiate the appropriate home program referral, and provide patient/family education related to the initiation of home care services.