Brenda Stevens

Provided palliative care services inpatient from 2015 to 2020, and in local nursing homes from 2020 through the present.

• Collaborate with physicians, hospital staff, and nursing home staff in identifying high-risk patients and developing patient-specific treatment plans, as well as symptom management.
• Goals of care discussions, advance care planning, and MOLST completion.
• Provided emotional support to families facing difficult decisions about a loved one's care.
• Support providers, patients, families, and caregivers to create patient-centered care plans based on diagnosis and social determinants of health. Assessed patient health and developed individualized care plans accordingly.
• Advocate for goal-directed care, provide compassionate end-of-life care, and patient and family education.
• Assessment and intervention of medical, social, and psychosocial issues.
• Champion advance care planning, MOLST education, eMOLST education, and outreach within the network and with select outside organizations/agencies, and participate in NY State MOLST committees.
• Provide education to HHHN providers and staff on the importance of upstream palliative care support, and function as an organization-wide resource to meet HHHNs' expanding palliative care needs.
• Intake and screening for new homebound and outpatient palliative care referrals.
• Participate in weekly, interdisciplinary team meetings.
• Provide PRI and SCREENs for HHHN patients in need of nursing home placement.
• Managed patient records using electronic health record systems efficiently.

• Responsible for the hiring, supervision, support, and motivation of the interdisciplinary team of nurses, social workers, spiritual care providers, volunteer and bereavement coordinators, and office coordinator in the day-to-day care of 20 to 60 hospice patients.
• Compliance with hospice Medicare guidelines.
• Review of documentation in EMR, admission, and recertification orders.
• Overseeing the budget, costs for medications, supplies, and equipment.
• Community and referral source outreach.
• Assist in the development of policies, procedures, and quality control.
• Patient care and on-call visits as needed, in addition to routine supervisor on-call duties.
• Triage of telephone calls and direct patients and families as appropriate.
• Problem-solving and conflict resolution.
• Assessment and intervention of medical, social, and psychological issues.
• Nursing and staff annual reviews and evaluations

• Assessment, triage, immunizations, and care of adult patients with a large geriatric population.
• Per visit, post-discharge planning, and medication reconciliation.
• Care coordination and case management.
• Triage telephone calls and direct patients as appropriate.
• Prescription refills.
• Coordination with other medical offices and community agencies.

• Responsible for the hiring, supervision, support, and motivation of the interdisciplinary team of nurses, social workers, spiritual care providers, volunteers, bereavement coordinators, and office manager in the day-to-day care of 15 to 30 hospice patients.
• Review of documentation in the EMR.
• Overseeing the admission, recertification, and discharge process as per Medicare guidelines.
• Overseeing the budget.
• Community, physician, and referral source outreach.
• Patient care and on-call visits as needed, in addition to routine supervisor on-call duties.

• Responsible for the hiring, training, supervision, support, and motivation of the interdisciplinary team in the day-to-day care of 15 to 30 hospice patients.
• Review of documentation in the EMR, admission, and recertification orders.
• Overseeing the admission, recertification, and discharge process per Medicare guidelines.
• Overseeing the costs, budget for medications, supplies, and equipment.
• Collaboration and outreach with physicians, community partners, and referral sources.

• Conducted patient assessments via telehealth platforms and documented findings.
• Maintained accurate electronic health records for all telehealth interactions.
• Assessed patient needs and collaborated with medical staff to provide patient education, guidance and instructions.
• Educated patients on self-care management techniques for improved health outcomes.
• Prescription refill line.
• Assist in urgent care as needed.
• Supervision of LPNs and medical assistants.

• Oversight of a fifteen-bed acute care unit and the emergency department of a small rural hospital.
• Assign, delegate, and evaluate patient care.
• Perform nursing triage, assessments, and care of emergent and non-emergent patients.
• Supervised nursing staff to ensure compliance with patient care standards.
• Coordinated patient admissions and discharges to streamline workflow efficiency.
• Maintained compliance with guidelines such as HIPAA and OSHA.

• Assessed patient needs and developed personalized care strategies for optimal health outcomes.
• Managed patient care plans and coordinated services with interdisciplinary teams.
• Educated patients and families on medical conditions and treatment options effectively.
• Documented patient progress and updated records in electronic health systems accurately.
• Collaborated with healthcare providers to ensure continuity of care for patients.
• Conducted home visits to evaluate patient conditions and adjust care plans accordingly.
• Performed case management functions such as referrals to community resources or other healthcare providers as needed.
• Utilized problem solving skills to assess complex medical situations and formulate appropriate interventions.
• Oversight of HHA, PCA, and LPN in their care of patients.

• Care management and care of terminally ill patients of all ages.
• Managed patient care plans in collaboration with interdisciplinary teams.
• Conducted comprehensive assessments to determine patient needs and preferences.
• Educated families on end-of-life care options and support services available.
• Documented patient progress and care interventions accurately in electronic records.
• Facilitated communication between patients, families, and healthcare professionals regularly.
• Maintained accurate documentation of patient progress in the electronic health record.
• Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
• scheduled home visits and on call visits.

• Service Coordination for Early Intervention Program.
• Participate in well-child and immunization clinics.
• Home visits for EIP, ICHAP, Family Services, and newborn visits.
• Managed patient care plans in collaboration with interdisciplinary teams.
• Conducted comprehensive assessments to determine patient needs and preferences.
• Coordinated services with healthcare providers and community resources efficiently.
• Documented patient progress and care interventions accurately in electronic records.
• Maintained accurate documentation of patient progress in the health record.

• Staff nurse in the ICU, medical-surgical floors, and Employee Health Coordinator.
• Administered medications and monitored patient responses during treatment.
• Provided education and support to patients and families regarding health conditions.
• Conducted assessments to evaluate patient health status and needs.
• Maintained accurate patient records and documentation.
• Provided direct nursing care to patients, including administering medications, wound care, and IV therapy.
• Responded quickly to life-threatening situations by providing appropriate interventions.