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Keywords: Conduct care-planning assessments to identify needs, problems and eligibility for assistance, Offer referrals to specialists to avoid future problems and conserve assets, Work with all the provider team to assure continuity of care, Encourage socialization and visit with the client to ensure their psychosocial needs are being met, Act as a liaison to families at a distance either geographically or relationally, Ensure things are going well and alert families of problems, Assist with moving/relocating clients to or from home, a rehabilitation facility, assisted living