The Case Manager assures timely, resource-effective transition planning, with respect for the patient and family as individuals within their psychosocial and cultural framework. Across the continuum of care, the Case Manager coordinates the planning of post-discharge services by collaborating with patients and their families, physicians, other members of the health care team, and representatives of payers and community agencies/facilities. The Case Manager assesses the psychosocial and clinical situation, assists patients and families in engaging in the discharge plan, accesses services, advocates for patients, and explores all possible options in order to achieve the highest quality clinical outcomes with the most cost-effective and timely use of available resources.