Heather Laurie

* Assist residents in adjustment to new environments and provided counseling for resident and family to assure psychosocial health and contentment.

* Handle and/or delegated resident support concerns respectfully to preserve residents' dignity, health and safety.

* Educate residents and families regarding private insurance, Medicare, Medicaid, Veterans Administration and other possible sources of funding for required care.

*Manage resident admissions and discharge and referrals to other facilities, home health agencies and hospice based on resident and family needs, preferences and resources.

*Prepare clients discharge by reviewing and amplifying discharge plans; coordinate discharge & post-discharge needs; orient & facilitate training for family

* Assist with arrangement of post-acute care such as home health services, durable medical equipment, IV infusions, outpatient dialysis or wound care, and specialist appointments

* Focus on client wellness & autonomy through advocacy, communication, education, and identification of service resources

* Monitor, evaluate, and record patient progress with respect to treatment goals. Facilitate communication regarding patient's progress between facility, client, insurance company, and/or providers.

* Create and implement individualized care plans in relation to patient's psycho-social wellness

* Advocate for the patient's needs and rights within a skilled nursing facility. Educate patients on their rights and options, so they are able to make informed decisions. Act as a liaison between patient and insurance companies to enhance communication in the continuum of care, especially in regard to barriers involving care/treatment and/or insurance coverage

* Coordinate with other service providers to ensure comprehensive care

* Conduct initial and ongoing psycho-social assessments, gathering relevant information for case management purposes to ensure all patient's needs are met during stay & post-discharge

• Responsible for discharge planning by assessing potential of patients and discussing potentials with clinical staff and arranging appropriate referrals to community agencies for a successful discharge to a community setting
• Knowledge of state of CT regulations and guidelines that govern nursing facilites
• Responsible for PASRR assessments, along with care planning appropriate recommendations provided by AssessmentPro
• Assist patients and/or families with Medicaid/QMB applications, SNAP, disability, and other state programs/grants
• Referral source for Hospice, ABI program, Money Follows the Person, and Elder Care program
• Address concerns, issues and/or needs with the appropriate department(s) to meet the needs of patients. Orchestrating appropriate resolutions, as well as, reporting and documenting all occurrences that may transpire. Completing & updating grievance log in a timely manner to meet standards of DPH guidelines
• Intervene in all resident conflict situations and provide crisis-intervention when needed
• Collaborate with local and state Ombudsman, when/if needed, to meet the needs of patients
• Clinical evaluator for referrals on Epic and Allscripts electronic charting. Reviewing referrals thoroughly to ensure the facility can meet the medical and psycho-social needs to ensure the best quality of care can be provided
• Participate in multiple community organizations to maintain network relations
• Supervise a small department, including yearly reviews of each persona;, as well as, approving weekly payroll
• Developed workable solutions for recurring problems for individuals and families
• Assisted clients in accessing community resources such as housing, food pantries, and transportation options.
• Improved outcomes and successes by utilizing multidisciplinary risk identification and management in care planning.
• Conducted assessments of client needs, strengths, and resources to develop treatment plans.

• Provided academic and emotional support to mainstream special education students into general classroom(s)
• Provide crisis management to special education students who exhibited high levels of aggression and/or emotional distress
• Provided student support through specialized accommodations, extra assistance and appropriate assessments
• Implemented behavior management strategies designed by special education staff members.
• Organized instructional materials for use in the classroom setting.
• Provided feedback on how well a student is progressing towards meeting their IEP goals.
• Maintained records of student progress and communicated results to parents and other school personnel.
• Assisted with transitioning from one activity to another throughout the day as needed by the student.
• Motivated students to achieve academic success while fostering an environment of respect and acceptance.