The Home Health Access RN provides quality, cost effective clinical coordination & transitions to the home from the acute care, emergency care settings, & clinic or primary care. The Home Health Access RN manages patients w/ routine & complex discharge planning needs through collaboration w/ inpatient &/or SNF care coordination. The Home Health Access RN also serve as expert resource consultants & educators for physicians & other health care team members in transitions of care to the Home Health Program, coordination of internal & community resources, & support the evaluation & improvement of systems of care to support the optimal utilization of home health resources, while maintaining quality of patient care.