Refers patients to a variety of resources including, but not limited to, Visiting Nurse Agency, Skilled Nursing facility, Long Term Care Hospital, Rehab Facility, Hospice Care, Durable Medical and Respiratory Care providers. In conjunction with patient, family, payers and other members of the health care team: formulates and implements a discharge plan to address assessed needs and patient/family concerns, evaluates the effectiveness of the plan in meeting the established care goals; and revises the plan as needed to achieve desired outcomes.