The Home Health Physical Therapist (PT) Case manager is a professional therapist who coordinates and directs the home care patient's services based on individual patient needs. The PT Case manager is responsible for independent management of the Home Health patient population requiring the use of advanced assessment, teaching and decision-making skills. The PT is responsible for ensuring that appropriate referrals to other services are made, interdisciplinary conference takes place regularly, and appropriate documentation is completed. Relevant knowledge and experience is consistently applied to new patient populations. The PT Case manager cares for a caseload of home health patients requiring therapy as the primary service by evaluating the patient for appropriateness of home health and developing the home care plan in conjunction with the physician. S/he educates patients, families, caregivers and community providers to safely perform care. S/he provides follow up by evaluating effectiveness of the home care plan, and monitoring patient/family's response to the plan to achieve patient/family goals and top decile outcomes. The PT Case manager also identifies performance improvement and home health standard of care initiatives and assists to design or implement programs to address needed changes.