The case manager is responsible for coordinating a patient-centered plan of care to meet individual needs by: Completing intake interviews to identify a holistic plan of care; facilitating multiple aspects of care coordination with the patient, family/caregiver, providers and other community resources prior to discharge. Developing a patient transition plan, providing patient/caregiver education and proactively advocating for patient needs and goals across the interdisciplinary team to ensure an approach that is sensitive to each specific patient and family’s needs.