I would like to recognize a group of individuals that work closely with patients, families, bedside nurses, therapists, dietitians, multiple physicians (surgeons, infectious disease, orthopedics, hospitalists, emergency room physicians, and not to mention the number of community agencies that are available to patients and families) and insurance companies. Recognizing that every patient is a unique individual and the group sees this as an opportunity to advocate for what each patient may need assistance at the time of their discharge. Each patient is not the same as the other, some may require a skilled nursing facility for rehab, some may require home health, and some are near the end of their life and need hospice care. It is the responsibility of these individuals to help them transition to the appropriate level of care. At times it sounds easy, but it can be difficult due to the uniqueness of each patient.

One particular case that was difficult was a patient that was on the east wing that Sarah worked on, this patient needed rehab, but just not a simple rehab, the patient needed intensive rehab due to having a traumatic brain injury. This was not a simple discharge, it took hours, multiple conversations, and a mother to have faith that Sarah was doing all she could do for her child. Wendy, who also works closely with the group also, helps patients get their needs met. Donna not only works with the patients and families she is often found working with insurance companies that have denied a patient's stay, sending information to them for them to eventually approve their stays. This group is required to know the multiple regulations of insurance laws, meanwhile orchestrating the transition that is most appropriate for each individual patient.