The Director will lead a team that directs and facilitates relationships among hospital, ambulatory, and community based providers for seamless continuity of care, including but not limited to physician offices, clinics, hospices, skilled nursing facilities, home health agencies, LTACs, and other post-acute and community entities. Develop programs for individual care planning and communication with community providers and agencies including identifying care needs, treatment goals and objectives, objective criteria for terminating specified interventions and mechanisms to document progress in meeting patient objectives across the care continuum.