Collaborate with physicians, discharge planners, social workers, and primary care providers for safe care transitions. Conduct patient assessments to identify barriers to successful discharge. Create and implement individualized care plans aligned with discharge instructions. Educate patients and families on medications, treatments, follow-up appointments, and lifestyle changes. Educate patients on recognizing warning signs for urgent care. Schedule and monitor adherence to follow-up appointments. Conduct post-discharge follow-ups via phone, telehealth, or in-person visits. Act as a liaison between patients, caregivers, and providers for clear communication. Document all interactions, progress, and follow-ups in electronic health record systems. Report patient outcomes to refine processes and improve care coordination. Work closely with multidisciplinary teams and participate in case reviews.