Joanne Aeed
Venice,FL
Summary
Dedicated and patient-oriented RN with over 25 years of diverse experience eager to accept new challenges and continue to foster exceptional working relationships with providers, payor sources, colleagues, and patients. Skilled in working under pressure and adapting to new situations to best enhance the organizational brand.
Overview
19
19
years of professional experience
1
1
Certification
Work History
RN Chronic Care Manager
Mass General Brigham/Wentworth Health Partners
Dover, NH
06.2018 - Current
- Manage a panel of patients identified as high risk-perform High Risk Assessments, ID Self Management Goals, and update accordingly
- Establish, implement, monitor, and evaluate high quality cost-effective plans of care for patients within MGB ACO in an outpatient Primary Care Medical Home model
- Foster trusting relationships with patients and their loved ones enhanced by frequent communication and outreach
- Manage all aspects of patient-centered care utilizing a medical home approach
- Work collaboratively with all members of the interdisciplinary team to include Providers, MSWs, DC planners, PharmD, BH, CDEs, patients and their loved ones
- Meet regularly with patients/families either in person, via Teams/virtually, or through patient portal or telephone to assess status and perform outreach
- Utilize EMR (Epic) and Microsoft Office suite and additional computer platforms as needed
- Coordinate with inpatient team, specialty practices, home health care, palliative care, hospice agencies, BEAS, DME companies, and a multitude of additional community service agencies to best meet patient needs
- Regularly perform record reviews to determine potential patients appropriate for care management services
Hospice Liaison RN
Cornerstone VNA & Hospice
Rochester, NH
July2013 - 05.2018
- Developed and maintained effective relationships with internal and external stakeholders
- Educated patients, families, as well as a multitude of referral sources on hospice philosophy, guidelines, and eligibility criteria
- Performed family meetings and evaluations on patients to determine eligibility for hospice as well as the most appropriate LOC
- Served as key corporate representative, liaising with various parties in support of operational excellence
- Collaborated with hospice interdisciplinart team to best meet the needs of patients and their loved ones
Home Health Care RN
Personal Touch Home Care
Londonderry, NH
07.2005 - 07.2013
- Assessed patient health and developed individualized care plans accordingly
- Provided direct nursing care to patients, including administering medications, wound care, and IV therapy
- Educated patients on health maintenance, disease prevention, and treatment options
- Performed physical examinations and assessments of patients' medical histories
- Collaborated with physicians and additional interdisciplinary team members in developing patient-specific treatment plans
- Maintained accurate documentation of patient records in accordance with HIPAA regulations
- Managed complex cases involving multiple diagnoses or treatments
- Advocated for patients by supporting and respecting basic rights, values and beliefs
Education
Master of Science - Public Health/Environmental Health
East Tennessee State University
Johnson City, TNBachelor of Science - Health Sciences
Worcester State University
Worcester, MAAssociate of Science - Nursing
Northern Essex Community College
Haverhill, MASkills
- Care Management
- Motivational Interviewing
- High Risk Assessments
- Cost-effective Care Planning
- Achieving desired outcomes
- Hospice
- Palliative Care
- Home Health care
- Home Healthcare Marketing
- Excellent relationship management
- Chronic Disease Management
Certification
- RN with Compact State License
- ANCC Certified in Care Coordination and Transitions (CCCTM)
- AHA BLS
- Trained Peer Supporter
Timeline
RN Chronic Care Manager
Mass General Brigham/Wentworth Health Partners
06.2018 - Current
Home Health Care RN
Personal Touch Home Care
07.2005 - 07.2013
Hospice Liaison RN
Cornerstone VNA & Hospice
July2013 - 05.2018
Master of Science - Public Health/Environmental Health
East Tennessee State University
Bachelor of Science - Health Sciences
Worcester State University
Associate of Science - Nursing
Northern Essex Community College
- RN with Compact State License
- ANCC Certified in Care Coordination and Transitions (CCCTM)
- AHA BLS
- Trained Peer Supporter
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