Answer:
(1) early identification and assessment of patients requiring assistance with planning for discharge.
(2) collaborating with the patient, family, and health-care team to facilitate planning for discharge.
(3) recommending options for the continuing care of the patient and referring to accommodations, programs, or services that meet the patient's needs and preferences.
(4) liaising with community agencies and care facilities to promote patient access and to address gaps in service.
(5) providing support and encouragement to patients and families during the stages of assessment from the hospital.