The Patient Care Facilitator is accountable for care coordination from admission to discharge for a group of patients on an assigned nursing unit.  For each assigned patient, the PCF functions in concert with the interdisciplinary care team and physicians to ensure the development and implementation of an individualized plan of care, daily (or more frequent) review and revision of the plan of care based on patient progress, and ongoing communication with the patient and family regarding expected outcomes of care.  The PCF is accountable for identifying and removing barriers that will prevent and/or delay a patient from reaching his/her outcome goals in a timely manner and for the development and execution of an appropriate discharge plan to address the patient’s post-acute care needs.