Debbie Wilson

• Nurse Case Manager for patient’s living with a serious or life limiting illness proving home and telephonic visits focusing on enhancing quality of life.

• Complete a comprehensive assessment of individual patients in including physical condition, health goals and needs and make recommendations to providers to manage distressing symptoms and improve quality of life.

• Work in collaboration with a team of professionals including Social Workers, Physicians, Nurse Practitioners, Chaplains, Volunteer Coordinators and Volunteers to develop a plan of care encompassing physical, social and spiritual needs.

• Provide education to patients, families and caregivers on disease management, symptom control, and coping mechanisms for illnesses such as Congestive Heart Failure, Diabetes, COPD, Chronic Kidney Disease, Parkinson’s Disease, Alzheimer’s Disease, Cancer and other chronic illnesses.

• Identify needs and assist patients to connect with community resources such as Home Health services, In-Home caregiving agencies, durable medical equipment, financial services,

Nutritional services, and more.

•. Provide assistance to clarify health goals and develop end of life plans, transitioning patients to hospice care when appropriate.

• Provided skilled nursing care in patient’s homes for a diverse range of medical conditions including post-surgical recovery, and chronic illness management.
• Managed time efficiently while visiting multiple patients daily, ensuring timely administration of medications and treatments.
• Educated patients and families regarding disease processes, interventions and lifestyle changes.
• Coordinated with physicians regularly regarding updates on patient conditions and recommended adjustments in treatment protocols when necessary.
• Educated patients and families on medication management, wound care, and healthy lifestyle choices to promote better outcomes.
• Demonstrated strong clinical judgment in assessing patients'' vital signs and recognizing early warning signs of potential complications.
• Collaborated with interdisciplinary healthcare teams to optimize treatment plans.
• Enhanced patient recovery by developing and implementing individualized care plans tailored to their specific needs.

• Processed referrals for Home Health, Hospice, and Palliative Care programs.
• Reviewed referrals to assure they met the requirements and regulations for all programs
• Developed relationships with and communicated with Providers, Case Managers and Discharge Planners to provide education on programs offered as well as items needed to process a complete referral
• Gained knowledge of insurance requirements while verifying benefits of many different t insurance providers.
• Worked closely with a team in a very fast paced environment.

• Traveled to 5 different hospitals as well as Skilled Nursing Facilities developing relationships with Case Managers and Discharge Planners and obtaining referrals for the Home Health agency.
• Evaluated referrals to assure they met all Home Health criteria and obtained necessary medical records from the patient’s chart.
• Met with patients and families to educate them on Home Health services and expectations and verify insurance and all demographic information.
• Entered referral information into EMS and coordinated with Home Health schedulers to ensure patients scheduled for timely admission to Home Heslth.