Participate in the Health Services Interdisciplinary Team (IDT) by scheduling and conducting weekly family care conferences and provide input to the weekly Medicare meeting, monthly triple check, and Prospective Payment System (PPS)/discharge planning meeting; and communicate with residents' families regarding the discharge process and post-discharge care requirements to achieve a smooth transition from the current level of care or from Montereau. Establish a trusting relationship with the residents and their families to orient and fully acquaint them with resources (i.e. Medicare and other insurance benefits) available throughout the continuum of services, the billing processes and resident financial responsibilities, and the specific schedule of services (i.e. mealtimes, bathing, etc.) in order to create a smooth transition from admission to discharge, including changes in level of care for the resident.