Essential Functions: Evaluates the patient's rehab potential, functional status (strength, mobility, gait, ROM, endurance, pain), home environment, DME needs, need for community resources and home health/hospice services through skilled observation and by administering age-specific tests. Coordinates the delivery of physical therapy services with nursing, social work, aide, therapy, equipment suppliers, community resources and transitions of care which results in effective utilization of resources and timely attainment of achievable rehabilitation and/or palliative care goals.