Discharge Planning & Care Coordination Conducts psychosocial assessments to identify barriers to discharge, including social, financial, environmental, and support needs. Develops individualized discharge plans in collaboration with RN Case Managers, physicians, nursing, therapy, and other team members. Coordinates post-acute services such as home health, DME, transportation, community resources, and follow-up appointments. Ensures timely communication with families, caregivers, and external providers. Facilitates safe transitions to SNF, IRF, LTACH, or home settings.