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- Educates physicians and staff and facilitates continuity of care of patients from hospital to home or hospice Participates on interdisciplinary team and collaborates with physicians and staff to establish and implement home care or hospice needs.
- Responsibilities: Communicates all appropriate patient information and coordinates staff availability directly with the home health or hospice intake department.
- Communicates home health or hospice staffing availability to referral sources and staff.
- Coordinates with the patient, patient’s family, referring physician, clinical care management representative, and hospital staff to determine the appropriateness of all home care referrals.
- Educates referral sources and other hospital staff in relation to home health or hospice services and regulatory requirements.
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