Ensures effective and timely coordination of client home care services through the timely completion of required documentation and computer data entry for new intakes, as well as the timely transfer of pertinent medical data to the client's physician, therapists, and agency staff members. Identifies home health patients' discharge planning needs when developing the plan of care; identifies and implements community referrals before patient discharge; determines patient readiness for discharge based on expected outcomes, goals, and coverage guidelines.