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The Discharge Planner coordinates patient transition along the healthcare continuum through assessments, referrals and interdisciplinary planning. Coordinates the post-hospitalization services as outlined in the patient's transition plan. The Discharge Planner provides the necessary focus on the patient's psycho-social, financial, and transition needs in order to promote optimal outcomes including reducing related and unplanned re-hospitalization. Refers patients to appropriate community services and resources. Alerts members of the interdisciplinary team to psycho-social and financial issues risk factors. The Discharge Planner applies the use of data in his/her practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool. This individual possesses excellent interpersonal, negotiation, and influence skills and works to effect positive practice changes that lead to improved value in patient care delivery.