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• Help patients and families determine their goals of care

• Facilitate advance care planning (DNR)

• Assist End of Life planning

• Reduce hospitalizations and ER visits

• Discuss psychosocial and spiritual issues that can arise

• Collaboration with all health care professionals for better communication, understanding and care of patients and their families

• Help to coordinate patient course of treatment and care

• Collaborate with clinicians regarding substance use disorder patients

• Maintain comprehensive and helpful treatment notes from every patient interaction

• Keep a collective file of all physician notes, test results and patient interactions for everyone that needs it from the medical team to the patient and family members - Good record-keeping  

• Update primary care or specialist following patient visits