Kaitlin Cipolla RN, BSN

• Reduced hospital readmissions by developing comprehensive discharge plans tailored to individual needs.
• Enhanced patient satisfaction by providing timely psychosocial assessments and interventions for diverse populations.
• Safeguarded patient rights, maintaining strict confidentiality in accordance with HIPAA regulations.
• Advocated for patients to secure necessary resources and services during hospitalization and postdischarge.
• Educated patients and families on available community resources, promoting self-sufficiency and autonomy.
• Maintained detailed case notes and documentation, ensuring accurate representation of patient progress.
• Navigated complex healthcare systems to coordinate optimal care for patients with multiple comorbidities.
• Maintained up-to-date knowledge of industry best practices and emerging trends through ongoing professional development activities.
• Developed trusting relationships with local service providers, streamlining the referral process and ensuring continuity of care for patients.

• Communicated with referral providers about new referrals and verified receipt of necessary information prior to arrivals.
• Facilitated timely referrals to alternate levels of care and assisted family or guardian with completion of applications.
• Worked with medical teams, patients and families to implement effective treatment plans.
• Documented case notes daily and coordinated follow-up for seamless case management.
• Quickly learned new skills and applied them to daily tasks, improving efficiency and productivity.
• Solved problems related to abrupt changes in discharge, coordinated updates and communicated discharge plans.
• Worked with multiple insurance agencies to establish prior authorization for timely discharges.

Acts as a member of an integrated health care team and instrumentation to it success while assisting HP members by removing barriers to care. Works in close proximity and collaboratively with Philadelphia FIGHT clinic at Broad Street Ministry for homeless population of Philadelphia.

• Serves as the primary care coordinator between the patient, the patient’s medical providers, behavioral health provider, pharmacist, dentist, hospital-based service providers, financial assistance specialist, residential and/or behavioral case manager, peer specialist, visiting nursing agency, community health worker and/or other specialists;
• Demonstrates extensive knowledge in clinical case management
• Completes physical and behavioral health assessments with members
• Educates and counsels patients/members and their families about issues including, but not limited to, medications, disease and disease management, stress reduction and healthier life-style choices.
• Demonstrates excellence in care management by coordinating care with intensive emphasis during care transitions.
• Works in conjunction with the Center for Behavioral Health to create care plans for members to achieve mental health goals

Member of the Community Based Care Management team assisting an internal medicine practice site with the coordination of care of high utilizer patients.

• Serves as a bridge between medical practice and insurance company resources.
• Facilitates communication between health agencies.
• Presents care plans for the long term management of chronic disease processes.
• Performs behavioral health assessments to provide patients with appropriate resources for mental health care.
• Works in tandem with Community Behavioral Health case manager to obtain informed consent.
• Aids patients with medication reconciliation and offers pharmacy support to ensure medication compliance.
• Supports patients with transitional care management after hospital discharge.
• Works in conjunction with a Community Health Worker to establish a working relationship with patients and accessibility to community resources.
• Connects patients to durable medical equipment to improve mobility outcomes.
• Documents in multiple electronic health record systems.
  

Served as an integral part of the non-fidelity Assertive Community Treatment (ACT) Team, that provided flexible, community based services designed to promote stability, recovery and community integration of formerly homeless individuals who are identified as medically fragile who have chronic illnesses, mental illness and abuse substances.

• Collaborated with ACT team members to coordinate client health services.

• Performed health assessments.
• Maintained a schedule for client prescriptions.
• Updated Medication Administration Records and in Credible electronic record.
• Monitored client vital signs, glucose, side effects of medications, etc. and report findings as required.
• Provided continuous client education re: mental illness, medication, and health issues.
• Worked with team and client in developing/following the optimal treatment/service plan.
• Collaborated with psychiatrists and other staff nurses in developing/delivering health, nutrition & fitness initiatives.
• Engaged identified clients in medical services, on-site and in the community.
• Provided health related in-service training and education for staff.
• Served as a health care resource to clients, families, staff and significant others.
• Participated in facilitating crisis interventions, referrals and hospitalizations as appropriate.
• Communicated with community medical and hospital staff re: optimal treatment/discharge.
• Documented all services provided in compliance with regulations.
• Participated in on-call rotation.
  

Research Assistant in the study titled: Pilot Test of a Pain Model: Focus on Instrumentation.

• Responsible for beginning and completing recruitment and consenting of subjects or of their direct power of attorney.
• Directly implemented assessment tools with subjects
• Accountable for accurate data collection and organization as well as general office duties.

Primary Investigator: Mary Ersek, PhD, RN, FAAN