Concetta DeFusco

• Led patient discharge planning, achieving discharge-to-community rates consistently above 87% (hospital goal: 70%).
• Maintained avoidable days under 5%, ensuring cost-effective patient care.
• Facilitated interdisciplinary care plans and coordinated services with physicians, nurses, therapists, and outside providers.
• Developed and led the 'Introduction to Case Management' program and stroke support/education groups.
• Served as interim Case Management Director, leading weekly team meetings to resolve barriers to discharge.
• Managed complex patient discharges involving skilled nursing facilities, hospice, home health care, and durable medical equipment.
  Advocated for patient needs and collaborated with VA resources and senior organizations such as COAAA.
  Conducted utilization reviews and coordinated with commercial insurance, Medicare, and Medicaid providers.
• Recognized with multiple awards, including 'Employee of the Month' (June 2022) and 'Stronger Together' awards for teamwork.
• Coordinated comprehensive care plans for patients, ensuring alignment with rehabilitation goals and discharge readiness.
• Monitored patient progress and modified treatment plans to enhance recovery outcomes and support interdisciplinary collaboration.
• Led weekly Team Conference meetings, providing insights that informed strategic decisions regarding resource allocation and service improvement.

• Managed a patient load of 20 to 25 medically complex patients, including those requiring wound care, dialysis, and ventilator support.
• Spearheaded complex discharge planning, ensuring individualized and safe transitions to home or other care facilities.
• Collaborated closely with an interdisciplinary team to facilitate timely ventilator weaning when appropriate, improving patient outcomes.
• Conducted comprehensive utilization reviews and coordinated with multiple healthcare providers to ensure optimal patient care.

Coordinated patient care plans in collaboration with interdisciplinary teams to enhance rehabilitation outcomes.

• Developed and implemented discharge planning strategies, ensuring smooth transitions for patients.
• Facilitated effective communication among healthcare providers, patients, and families to streamline care delivery and foster understanding.
  Conducted assessments to identify patient needs, developing tailored interventions that promote physical and emotional well-being.
  Analyzed trends in patient data to identify areas for improvement, driving initiatives that enhance operational efficiency within the department.

• Customized discharge plans to address unique patient needs across physical, psychological, and environmental factors.
• Collaborated with interdisciplinary teams to align treatment plans with patient goals and realistic outcomes.
• Attended administrative and operational meetings as needed to support hospital initiatives.
• Maintained compliance with CARF accreditation standards and contributed to five successful surveys.
• Completed internship at Ball Memorial Hospital (Jan – May 2009), which led to full-time hire.