A client is scheduled for discharge. Which member of the interdisciplinary team is MOST appropriate to coordinate referrals for home health services and community resources?

INTERDISCIPLINARY TEAM COORDINATION and knowing when to involve each team member is a core NCLEX-PN coordinated care competency. SOCIAL WORKER ROLE in discharge planning: INSURANCE AND BENEFITS: expertise in Medicare, Medicaid, private insurance coverage for home health, skilled nursing facility, and rehabilitation services; COMMUNITY RESOURCES: knowledge of local agencies, support groups, meals programs (Meals on Wheels), transportation, housing assistance; HOME HEALTH COORDINATION: can arrange skilled nursing visits, physical therapy, occupational therapy, speech therapy, home health aide services; COMPLEX SOCIAL SITUATIONS: homelessness, domestic violence, elder abuse, substance use, mental health resources; FINANCIAL ASSISTANCE: medication assistance programs, patient assistance foundations; ADVANCE CARE PLANNING: assistance with advance directives, health care proxies, living wills. THE PN'S ROLE IN DISCHARGE: assess the client's understanding of discharge instructions; reinforce teaching; identify concerns or needs to report to the RN or social worker; document; the PN does NOT independently coordinate complex discharge arrangements — that is above PN scope. INTERDISCIPLINARY TEAM MEMBERS AND THEIR PRIMARY ROLES: RN — clinical coordination, complex discharge assessment, care coordination; LPN/LVN — implementing care plan, assessment under RN supervision, patient education (reinforcement), reporting; SOCIAL WORKER — psychosocial assessment, community resources, discharge planning; PHYSICAL THERAPIST — mobility, strength, balance, gait training; OCCUPATIONAL THERAPIST — ADLs, adaptive equipment, home safety; SPEECH-LANGUAGE PATHOLOGIST — swallowing, communication; DIETITIAN — nutritional assessment and counseling; CHAPLAIN — spiritual care; PHARMACIST — medication reconciliation and counseling; CASE MANAGER — insurance authorization, utilization review.