Joanna Gutierrez

• Coordinated patient referrals to facilitate timely access to hospice services, with the motto of "same-day contact."
• Maintained accurate electronic health records to ensure seamless information flow.
• Communicated with external healthcare providers from hospitals, nursing facilities, and rehabilitation centers regarding patient needs and statuses to enhance care.
• Collaborated with multidisciplinary teams to strengthen patient support services, such as the medical director, nurses, social workers, and chaplains.
• Scheduled patients based on availability, and gathering needed information for a successful start. Example is requesting charity services when needed for clients without Social Security or insurance.
• Resolved inquiries and concerns raised by patients and specialists promptly.
• Ordered medical equipment to the location needed.
• Scheduling ambulance transportation when needed.
• Kept the patient, family, healthcare providers, and internal team aware of the status to ensure a smooth transition.
• Trained new employees on organizational referral policies and procedures.

• Facilitated community outreach programs to enhance resident engagement and support services.
• Collaborated with local organizations to create partnerships that strengthen community resources.
• Organized workshops to educate the community on available resources and support services.
• Created positive learning environments for adults through arts and crafts projects such as sewing, ESL, social groups, and Zumba.
• Worked with team members to achieve goals, including working in different locations.
• Organized Community Center space, including ordering supplies, setting up equipment, and ensuring the cleanliness of the work area.
• Coordinated community events such as health fairs or seasonal celebrations, to foster engagement and collaboration among the community.

• Provides information on community services to individuals identified with intellectual disabilities or related conditions, who are currently living in a nursing facility. Provides an educational tour of the group homes and community resources.
• Gathers historical, psychiatric, developmental, social, functional, and any information needed to assist the psychologist in determining eligibility to complete the service coordination assessment.
• Ensures required notes and documents are turned in a timely matter and up to date.
• Joins quarterly meetings with nursing facility and advocates for individual if needed.
• Coordinate transfers working with individual, family, nursing facility, relocation specialist and provider to ensure safe transfer to community placement.
• Attends meetings with Community Transition Team to identify barriers of placements, address issues with ombudsman if issues arise and gather updated information of community resources available to the individual.

To maintain the facility and care for residents as needed.

• To ensure all boundaries and policies are being followed according to facility guidelines.
• Assistance with self-medication as scheduled or PRN, under the guidelines of the Pharmacy.
• Encourage and/or assist with daily living activities, including, but not limited to, showering, hygiene, cleaning, and laundry.
• Maintain the facility by utilizing teamwork in tasks such as washing dishes, sweeping, washing linens, making beds, and mopping.
• Provide transportation to places such as the hospital or pharmacy.
• Assist individuals in crisis if they need EMS, PD, or a crisis hotline, and be an advocate if needed.