Joanne Aeed, RN, MS, CCCTM

*Manage a panel of approx 180 patients that have been identified as high risk; perform High Risk Assessment, identify Self Management Goals and update accordingly on each patient.

*Establish, implement, monitor, and evaluate high quality cost-effective plans of care for patients in ACO outpatient setting who have Medicare, Medicaid, Managed Health Plans.

*Utilize a medical home approach to manage all aspects of patient-centered care.

*Directly interface with physicians, APPs, all members of interdisciplinary team as well as patients and their families to improve patient outcomes.

*Communicate via telephone, pt gateway, Teams, and use of desktop management accessing and reviewing records of patients at increased risk in order to assure treatment plans are optimized to mitigate such risks.

*Educated patients and their families, as well as referral sources, on hospice philosophy, guidelines, and benefit.

*Performed Evaluations on patients and was responsible for determining Hospice eligibility.

*Collaborated with Hospice Interdisciplinary Team to meet the needs of patients and their families.

*Provided skilled nursing care to individuals in their homes utilizing best practices.

*Performed admissions to services for patients with a variety of insurances to include Medicare, medicaid, Private insurance, managed plans.

*Educated patients and families on disease management, medications, wound care, etc.

*Worked with patients in developing personalized plans of care to achieve optimum outcomes.