Cindy Schreiber

Hired with the PHSO as an Acute Care Coordinator which involved following all ACO attributed patients while hospitalized. In this role I worked onsite at MercyOne Medical Center. I attended patient care rounds and assisted the interdisciplinary team to achieve best outcomes for patients. Once our facility went live with Epic as our EHR our role was transitioned to the High Risk Transition Coordinator role.

I currently work remotely and outreach to the high risk patients discharged from MercyOne Waterloo. These include patients with high readmission rate scores and high risk diagnosis and multiple comorbidities. My responsibilities are:

• Facilitated appointments and transportation for patients, streamlining access to essential medical services.
• Determined need for special assessment activities for complex cases, effectively handling care plans.
• Streamlined information sharing between healthcare providers by implementing secure electronic communication systems.
• Developed patient education materials on chronic disease management, empowering patients to take active role in their health.
• Implemented patient follow-up procedures to monitor treatment progress and adjust care plans as needed.
• Communicated with patients, ensuring that medical information was kept private.
• Discussed medical histories with patients in effort to provide most effective medical advice.
• Advocated for patients'' rights within the healthcare system, working diligently to address concerns or barriers to care.
• Improved communication among healthcare providers, streamlining the coordination of services for patients.

• Work in all acute areas ICU, Medical/Oncology, Ortho/Neurosurgery, Cardiac/Renal units
• Review patient charts to ensure they are at the appropriate level of care
• Utilization Review utilizing InterQual criteria
• Make appropriate referrals to an outside physician review agency for Medicare and Medicaid patients
• Assess patient needs and make appropriate referrals
• Attend daily interdisciplinary rounds to discuss patient needs and discharge planning
• Communicate with physicians, staff, patients and family members as needed to ensure needs are met
• Obtain orders from physicians as needed
• Work closely with all teams members to ensure the best discharge plan for high risk patients
• Strive to prevent readmissions by ensuring the best discharge plan is in place
• Provide clinical information to insurance companies for authorization and continued stays
• Resource to all staff, physicians and patients.
• Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
• Coordinated care conferences with interdisciplinary team members, ensuring all perspectives were considered in the development of comprehensive treatment plans.

• Cared for adult patients in both charge nurse and staff nurse role
• Administered chemotherapy
• Rounded and communicated with physicians and staff to ensure patient needs were met.
• Provided compassionate and empathetic support to patients and their families during difficult situations.
• Mentored new nursing staff, contributing to a more cohesive and efficient team environment.
• Managed complex wound care cases using advanced skills in assessment, dressing application, and infection control measures.
• Evaluated the effectiveness of nursing interventions, revising care plans as needed to ensure optimal patient outcomes and satisfaction.
• Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.

• Administrator of new branch office that opened in Oelwein, IA
• Hired and trained all staff
• Admitted all new clients and did in home visits for current clients in all of NE Iowa
• Involved in state survey
• All administrative and general office duties.

• Care of patients with brain injuries, spinal cord injuries, and other neurological disorders
• I also did part-time work for Hawkeye Home Health during this time in caring for a pediatric ventilator dependent quadriplegia in their home from 1993-1995.
• Educated patients on disease prevention and management, promoting healthier lifestyles.
• Assisted physicians during medical procedures, ensuring accurate delivery of care as prescribed by the healthcare provider.