Josephine Ottah

-Responsible for all care management duties and providing comprehensive care coordination, including monitoring the Participant's Life Plans according to everyone's unique circumstances.

-Responsible for scheduling, leading, and actively collaborating with the Participant Consumer Advisory Board (CAB) and other IDTs to conduct meetings and assessments, ensuring the development of a comprehensive Life Plan that reflects the person's needs and desired life goals.

-Utilizing planning tools such as Individualized Assessment Measures (IAM), Council of Quality and Leadership, Personal Outcome Measures, the Coordinated Assessment System, Developmental Disability Profile, the Level of Care, the Comprehensive Emergency Plan, Environmental Assessment, and Care Giver Adequacy Assessment.

-Implement, update, and monitor Life Plans, and facilitate individualized Life Plan reviews and approval processes at a minimum of every six months or when a trigger event occurs.

-Ensure integration of all needed and preferred supports and services (i.e., medical, behavioral, social, habilitation, dental, psychosocial, and community-based, and facility-based long-term supports and services, etc.)

-Communicate with IDT, physicians, and other providers at regular intervals to monitor and update Life Plans, and to advocate for participant needs and preferences.

-Provide education to participants, caregivers, circles of support, IDTs, and other stakeholders.

Maintain participant Life Plan and health risk assessment information in a secure system, and meet all confidentiality requirements.

- Conduct monthly, in-person visits per OPWDD requirements.

- Conduct hospital discharge meetings with hospital staff, Consumer Advisory Boards, and other IDTs before the member's discharge after a 7-day hospital admission.

-Ensure post-hospital discharge referrals are maintained by family care members and residential provider agencies.

Promote PHP's mission and values.

-Utilize a person-centered approach, supporting an individual's preferences and desires, to promote reaching their highest level of independence.

Maintain ongoing contact with the critical people in a participant's life, as appropriate.

Ensure timely submission of all documentation (Life Plan, Progress notes) per regulated time frames.

Assist individuals in ensuring the maintenance of entitlements, including recertifications, guardianship, and informed decision-making.

Assists members with maintaining benefits such as Social Security, Supplemental Security Income, Medicaid, Medicare coverage, and Food Stamps.

_ Monitoring benefits for individuals whose representative's payee is the agency operating their certified residence and assisting individuals with their benefits, when the individuals do not have a representative payee or when the non-residential representative payee requests assistance.

Assist individuals in resolving problems in living, such as housing, utilities, the judicial system, and general safety.

Responsible for advocating for and with an individual to ensure informed decision-making, informed consent, and guardianship that is appropriately carried out.

Report abuse or neglect immediately when observed.

• I serve as the single point of contact for 40 caseloads in care coordination and management.
• I assisted in coordinating and supporting services for members requiring Social Security benefits and Medicaid-Medicare Certification.
• I utilized a person-centered approach in supporting 40 participants to be as independent as possible.
• Interacted with members monthly, telephonically, virtually, and face-to-face to ensure adequate care and service plans were maintained.
• Conducted comprehensive assessments and reassessments for trigger events.
• Conducted Personal Outcome Measures (POM), level of care determinations, and psychosocial and psychological updates.
• Collaborated with caregivers on self-management and coordinated support required for service authorizations.
• Facilitated interdisciplinary care team meetings during members' life plan development, with advocates and service providers.
• Report data collection and entry according to the Office of People with Developmental Disabilities (OPWDD) standard.
• Created, wrote, and approved Life Plans.
• Utilized electronic records documentation systems, such as Medisked and OPWDD CHOICES.
• Coordinated referrals to over 40 primary care doctors, specialists, hospitals, ancillary testing, and other services of members' choice.
• Provided advocacy for clients to ensure their needs are met through appropriate services.
• Assisted clients in developing and achieving short-term and long-term goals.
• Participated in team meetings with other staff members to discuss case management issues.
• Monitored client's compliance with medications prescribed by physician or psychiatrist, if applicable.
• Attended court hearings related to guardianship or conservatorship cases involving clients.
• Coordinated with other health care providers, such as physicians and psychiatrists, to develop comprehensive treatment plans.
• Conducted assessments of the client's physical, psychological, cognitive, social, economic, and environmental needs.
• Developed service plans based on assessment findings; monitored the effectiveness of plans regularly.
• Facilitated the coordination of medical appointments and transportation for clients when needed.
• Arranged referrals for additional services such as housing assistance or financial aid programs when needed.
• Served as a liaison between clients' families and community agencies providing services to them.
• Collaborated with local schools, daycare centers and employers regarding special accommodations for clients' disabilities.
• Provided counseling sessions to individuals or groups focusing on behavior modification techniques.
• Evaluated potential living arrangements for clients including independent living facilities or supervised residential settings.
• Organized recreational activities that promote physical activity and positive interactions among peers.
• Ensured that all documentation is completed accurately according to state regulations.
• Participated in continuing education courses related to mental health topics.
• Developed and implemented acare management plan to address needs and goals.
• Created plan of care to assist patients in reducing problems or barriers to achieve optimal level of health.
• Maintained daily living standards by assisting clients with personal hygiene needs.
• Facilitated communication between members of health care delivery while involving clients in decision-making processes to minimize service fragmentation.
• Attended and actively participated in meetings to provide and receive information on patient progression.
• Monitored care plan to evaluate effectiveness, document interventional achievement and suggest changes.
• Promoted integrations of long-term services and support to enhance continuity of care.
• Used motivational interviewing to educate, support, and motivate change.
• Monitored vital signs and medication use, documenting variances, and concerning responses.
• Audited charts to drive accurate and thorough documentation, supporting reimbursement of services rendered.
• Assisted with meal planning to meet nutritional plans.
• Collaborated with the outpatient team to identify patients for handover and post-discharge follow-up.
• Monitored and evaluated the effectiveness of care plans, making adjustments as necessary to meet clients' evolving needs.
• Collaborated with the outpatient team to identify patients for handover and post-discharge follow-up.
• Collaborated with the outpatient team to identify patients for handover and post-discharge follow-up.
• Provided crisis intervention services as needed, ensuring client safety and access to appropriate resources.
• Educated clients and families on disease management, prevention strategies, and healthy lifestyle choices.
• Conducted regular follow-up with clients to assess satisfaction with services and identify any unmet needs.
• Participated in continuing education and professional development activities to stay current with best practices in care management.

• Coordinated, developed, and wrote individualized day habilitation and pre-vocational service plans
• Conducted monthly face-to-face home visits, assessment, psychosocial and psychological updates, and level of care determination
• Led Personal Outcome Measures (POM) conversations with members and advocates
• Maintained participants' electronic records system utilizing Evolve, Medisked, and CHOICES
• Provided community habilitation services for foster children under the Bridges to Health (B2H) program
• Assisted foster children with coordinated goals and valued outcomes of their choices
• Referred members and their families to appropriate educational and legal resources, organizations, and community agencies to meet treatment needs
• Referred clients to appropriate team members, community agencies, and organizations to meet treatment needs

• Implemented plan of care approved for participants with developmental disabilities
• Enhanced quality of life for participants by encouraging independence of choice-making
• Assisted and implemented community support services in alignment with participants' needs
• Provided and assisted participants in areas such as educational, recreational, productive work experiences, and community exploration activities of their choices
• Served as advocates for 40 participants according to their identified needs and interests
• Supported participants in developing goals and social skills, improving individual wellness and productivity