Angel Johnson

Independently complete initial assessment, coordinate and implement a timely safe patient discharge plan.

Participate in an interdisciplinary approach to patient care management.

Provide emotional support and psychosocial counseling to patients. Provide community resources, assisting in setting up home health, wound vac, trach supplies, tube feeding IV antibiotics, subacute rehab, acute rehab, long term acute care facilities, hospice for inpatient or home hospice, out patient dialysis, and transportation

Consistently arranged subacute rehab and nursing home placement.

Identified nursing facilities, track referrals and communicated information regarding placement back to the social worker in a timely manner. Maintain on going communication with key staff at nursing facilities. Provided family members and Doctor's office in the community with resources regarding nursing home placement.

Independently completed assessment, coordinated, and implemented a timely, safe patient discharge plan.

Participated in an interdisciplinary approach to patient care management. Provided community resources, set up home health services, wound vac, trach supplies, tube feeding, IV antibiotics, subacute rehab, acute rehab, long-term acute rehab, inpatient hospice, home hospice, outpatient dialysis, and transportation.

Provided emotional support and psychosocial counseling to patients.

• Perform medical record reviews for admissions and continued stay criteria, and ensure documentation accurately. Responsible for discharge planning activities and collaborating with physicians and other healthcare disciplines. Use clinical expertise and problem-solving skills to achieve optimal clinical and resource outcomes in an effective time frame.

Provided counseling and bereavement services to patient and families. Evaluated coping skills in crisis

situations. Assist patient and family in utilizing community resources. Completed initial assessment, progess notes and care plans.