Facilitate bi-directional communication to enhance the handover of care from one setting and arrange, ensure all elements of the transition plan are implemented and communicated to key stakeholders including, not limited to, the health care team, patient, family, caregiver, payers and post-acute providers. Screen all patients for clinical, psychosocial, financial and other factors that may affect the progression of care and collaborate with patients, families, caregivers in goal setting that is reflective of the patients needs.