Jan-Rhys Emperio
Oakland,CA
Summary
Experienced Patient Care Coordinator specializing in discharge planning and care coordination. Develops individualized care plans and enhances patient outcomes through effective communication and interdisciplinary collaboration. Navigates healthcare systems and refers community resources to support smooth patient transitions.
Overview
15
15
years of professional experience
Work History
Patient Care Coordinator/Discharge Planner Nurse Case Manager
Kaiser Permanente Hospital
San Francisco, USA
11.2016 - Current
- Coordinate and anticipate Discharge Plan needs of various Medical-Surgical Units in KP, SF; including but not limited to: Cardiovascular Surgery, Ambulatory and General Surgery, Orthopedic, Med-Surg/Telemetry Units, Emergency Department and Intensive Care Unit.
- Developed discharge planning assessments and individualized care plans to ensure quality continuity of care for inpatients and post-hospitalization.
- Reviewed level-of-care appropriateness and anticipated medical and social needs of patients in acute care setting, enhancing patient-centered care.
- Collaboratively work with a Multidisciplinary team to deliver efficient Holistic care.
- Educated patients, families, and caregivers on navigating Kaiser Permanente healthcare benefits, co-pays, and resources to optimize access to necessary services.
Care Coordination Nurse Case Manager
Health Plan of San Mateo (HPSM)
03.2015 - 11.2016
- Coordinated case management for HPSM members under primary care providers in North & Coastside Physician Panel to ensure continuity of care.
- Initiate Individualized Care Plans with identified High Risk members with their Primary Care Provider to meet short and long term goals.
- Develop Individualized Care Plans from Health Risk Assessments (HRA's), interactions from members and providers to enhance health outcomes for all HPSM members.
- Facilitated discussions on treatment and management of HPSM members' co-morbidities, identifying knowledge deficits and providing education on interventions to achieve health goals.
- Engaged HPSM members and care teams to navigate healthcare management of co-morbidities, contributing to improved overall health outcomes.
- Educate HPSM members, family members, caregivers and providers on benefits and community resources to maintain HPSM members in the community setting.
- Make referrals to community based organizations and coordinate with an Interdisciplinary Team to support, advocacy and education.
- Serve as a Dementia Care Specialist for the Alzheimer's Association to identify HPSM members in need.
- Participate in monthly HPSM Informatics meetings to identify and enhance Health Services workflows.
Home Health Registered Nurse/Case Manager
North Cal. Home Healthcare
10.2013 - 03.2015
- Completed Oasis-Start of Care C1 initial assessment to determine patient home health care needs and establish appropriate services.
- Provided Skilled Nursing visits and managed Case Management duties under personalized goal-based Plan of Care to enhance patient outcomes in home environment.
- Collaborate with a multidisciplinary team of Physical Therapists, Occupational Therapists, Medical Social Workers and Home Health Aides under the Director of Patient Care Services to provide patients and their families/caregivers with goal centered outcomes for optimum home health safety.
- Develop a care plan which establishes specific goals, based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
- Initiated preventive and rehabilitative nursing procedures. Administered medications and treatments as prescribed by the physician.
- Regularly re-evaluate patient's nursing needs and make necessary changes to manage patients and their co-morbidities and knowledge deficits to maintain them in the community setting.
- Educate patients and their families/caregivers medications, management of disease processes and co-morbidities, maintenance of optimum home health safety per assessment and plan of care.
- Identified and implemented discharge planning needs within care plan development to ensure smooth transitions for patients prior to discharge.
- Translate to patients and their families/caregivers Medicare, Medi-Cal and Private Insurance policies and expectations of Home Health Care to meet patient needs. Documents patient progress in a timely and accurate manner.
- Participate and at times lead bi-weekly care coordination meetings with a multidisciplinary team and monthly company in-services to provide patients and their families/caregivers needs.
Home Health Registered Nurse/Case Manager
Blize Home Healthcare
12.2012 - 10.2013
HIV-AIDS Specialty Registered Nurse
Rivington House SNF
07.2011 - 12.2012
- Assess, diagnose, identify, plan, implement and evaluate care for residents who are HIV symptomatic/AIDS and related co-morbidities.
- Administer and evaluate response of oral, subcutaneous, intramuscular, intradermal and intravenous medications.
- Delivered direct care to residents needing partial and total assistance during Anti-Retroviral Therapy, enhancing patient comfort and adherence.
- Alternating Charge Nurse of 30 residents of SNF exclusively for HIV symptomatic/AIDS residents.
- Conducted patient admissions, completing full history, physical and safety assessments, and medication reconciliation to ensure comprehensive care.
- Collaborate with a multidisciplinary team to deliver holistic care to residents who are HIV-Symptomatic/AIDS and related co-morbidities.
- Participate in weekly comprehensive care plan meetings to deliver holistic care.
- Completed Minimum Data Sets (MDS) for residents to facilitate accurate Medicare/Medicaid reimbursement, ensuring timely financial support for health care facility.
Education
Bachelor of Nursing - Nursing
William Paterson University of New Jersey
Wayne, NJ06.2010
Skills
- Discharge planning
- Care coordination
- Patient assessment
- Discharge coordination
- Follow-up care coordination
- Individualized care plans
- Healthcare navigation
- Community resource referral
- Medical documentation
- Admissions processes
- Discharge documentation
- Effective communication
- Patient communication
- Interdisciplinary collaboration
- Active listening
- Interpersonal skills
- Health education
Timeline
Patient Care Coordinator/Discharge Planner Nurse Case Manager
Kaiser Permanente Hospital
11.2016 - Current
Care Coordination Nurse Case Manager
Health Plan of San Mateo (HPSM)
03.2015 - 11.2016
Home Health Registered Nurse/Case Manager
North Cal. Home Healthcare
10.2013 - 03.2015
Home Health Registered Nurse/Case Manager
Blize Home Healthcare
12.2012 - 10.2013
HIV-AIDS Specialty Registered Nurse
Rivington House SNF
07.2011 - 12.2012
Bachelor of Nursing - Nursing
William Paterson University of New Jersey