Assess and develop personalized care plans for patients recovering from injury, surgery, or illness.
Facilitate the discharge planning process by preparing patients and families for a smooth transition to home or other care settings, ensuring all necessary medical and personal support services are in place.
Coordinate with a multidisciplinary team of doctors, nurses, and therapists to deliver quality care and services.
Dialysis Social Worker
Fresenius Medical Care
05.2024 - 10.2024
Assess patients' psychosocial status, strengths, and areas of need that may affect rehabilitation.
Reduce hospital readmission rates by coordinating post-discharge planning activities that ensure continuity of care for high-risk individuals.
Improve client self-sufficiency with personalized case management and resource coordination.
Medical Social Worker
The Elizabeth Hospice
07.2023 - 02.2024
Managed caseload of 50 patients and their families.
Educated patients on available treatment options and assisted in informed decision-making regarding their healthcare plan.
Offered crisis intervention services to address urgent concerns related to mental health, substance abuse, or domestic violence issues.
Medical Social Worker
Comfort & Peace Hospice
10.2022 - 05.2023
Participated in the training, orientation, and evaluation of new MSWs.
Collaborated in interdisciplinary team meetings on developing and reviewing individualized patient care plans.
Coordinated discharge plans from hospitalization to home or long-term care facilities.
Medical Social Worker
Hospice of the North Coast
08.2019 - 09.2022
Conducted initial and ongoing biopsychosocial assessments of terminally ill patients and their families within home and inpatient settings.
Assisted Veterans and their families in navigating and gaining access to VA health care, pensions, disability, insurance benefits, and burial allowances.
Facilitated care conferences to promote interagency collaboration and mediation of complex family dynamics.