Coordinate patient care from a distance, primarily using phone or video communication, focusing on assessments, developing care plans, and ensuring patients access necessary resources and support Identify process improvement through data collection and auditing Exhibits clinical excellence, strong communication and ensures the highest quality of care. Use home health expertise to triage patient needs and maintain open communication with patients, caregivers and other healthcare providers. Manages holistic picture of individual/family/caregiver to promote overall health and wellbeing with focus on patient centered care Facilitates health optimization by progressing the plan of care from admission to discharge by determining the appropriate utilization of services Responsible for the collaboration between the interdisciplinary care team by identifying goals and coordinating the plan to ensure patient safety Creates engagement by taking responsibility for their professional development and other team members as evidenced by leading case conferences, assisting team member in-services, acting as a clinical resource and staff meeting input