Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances.. ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment. ORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriate. MEDICATION - (UPC and CPC Only) Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings. PATIENT CARE - (UPC and CPC Only) Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions