Develops a Plan of Care to promote optimum function and safety as documented in the clinical record: Partners with patients and caregivers to establish goals for Plan of Care based on an episodic care model, Establishes interventions and specific measurable outcomes that are consistent with identified needs and strengths, Identifies goals, outcomes and timeframes that are realistic, measurable and address functional needs and strengths, Assists other therapists to design and implement episodes of care in collaboration with the patient/family, Modifies and updates the plan of care based on patient progress and caregiver input, Supports modifications to the plan or care with documentation of clinical decision-making in reports, notes and progress summaries. Coordinates patient care with other clinical team members ensuring optimal patient care and communication as noted in the clinical record: Identifies the need for and makes referrals to other disciplines following established criteria.