FLORENCE MITCHELL

• Improved patient outcomes by consistently providing comprehensive assessments and developing tailored care plans by 95%.
• Enhanced interdisciplinary team communication through regular case conferences, promoting effective collaboration for optimal patient care.
• Streamlined care coordination processes to reduce hospital readmissions and emergency department visits.
• Evaluated patient progress and adjusted care plans accordingly, ensuring continuity of care across all healthcare settings every 30 days.

Conducted comprehensive assessments of patients'' physical, emotional, and social needs in order to develop individualized care plans that facilitated optimal health outcomes on every visit.

• Collaborated with physicians and other healthcare providers to ensure appropriate resource utilization for complex cases per Medicare guidelines.
• Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
• Performed evaluations on consistent basis to address changes in patient needs, conditions and medications, altering care plans when required every 30 days.

• · Assessed and reviewed patients for discharge and planning and integrated services for patients requiring home care, home infusion and durable medical equipment (DME).
• · Determined and coordinated appropriate level of care to meet individual patient needs.
• · Actively participated in family and patient planning processes every 60 days.
• · Updated and maintained discharge plan of care with physician, members of healthcare team, patients and families.