Performs patient comprehensive assessments and collaborates with patient multi-disciplinary care team (PT, OT, ST, MSW, and paraprofessionals) to develop, modify, and implement an individualized patient plan of care, per physician orders that ensures quality treatment, proper discharge planning and achieves desired outcomes and goals. Collaboration: Helps to achieve and maintain continuity of patient care by communicating information, including changes in plan of care, new orders, lab results, and new referrals promptly.