Clinical Practice and Care Management Performs psycholosocial/physiologic assessments that integrates changing data Formulates a plan of care based on trends of similar patients, including patient education and discharge planning. Tailors and prioritizes caring practice to individual needs, including cultural/ ethical/ spiritual needs. Participates in the planning of routine transitional health care needs. (. treatment options patient placement options, end of life options) Responds to changes in patient's needs and provides holistic care using independent clinical judgment based on knowledge drawn from education and experience. Adapts planned educational programs and information to individual patients and family by modifying teaching strategies or content. Integrates education during the delivery of patient care. Collaborates with patients/ families to identify realistic desired outcomes. Ensures efficiency in the delivery of care: determines i...