The Hospice Transitions RN, as a member of the Advanced Care Management department, identifies, assesses, and prepares hospitalized patients and their loved ones for the transition to end-of- care. Coordinates the discharge plan, problem solves, and documents actions and plans while collaborating, consulting, and advocating on the patient’s behalf. Holding continuity of care as a priority, communicates and coordinates with the larger healthcare team including the hospitalist, nurse, patient care facilitator, social worker, and palliative care.  Receives and follows up on hospice referrals by meeting with the patient/family, introducing hospice services, evaluating the patient’s status, eliciting choice for post-acute providers, facilitating orders, and anticipating needs for equipment, medication, and transportation