Kristia (Kristi) O’Steen-Green, MSW

• Conducted thorough assessments of patient needs, goals, and preferences for end-of-life care.
• Developed individualized care plans addressing emotional and social needs of patients.
• Delivered supportive counseling for families facing terminal illness and end-of-life challenges.
• Advised caregivers on coping strategies for the physical and emotional demands of terminal illness.
• Provided crisis intervention during acute distress or changes in patient condition.
• Educated families on community resources and services, reducing caregiver burden.
• Attended interdisciplinary team meetings to collaborate, advocate, and enhance patient care planning decisions.
• Managed caseloads by prioritizing tasks based on urgency to ensure timely support.
• Attended continuing education seminars related to hospice social work practices.

• Coordinated access to essential medical and long-term care services, enhancing orientation care plan development.
• Conducted assessments with members, caregivers, or providers to evaluate client needs and service requirements.
• Authorized and coordinated referrals for benefits and services.
• Ensured uninterrupted provider service delivery while identifying gaps in care plans.
• Facilitated integration of informal or voluntary services into member care plans, improving overall care coordination.
• Monitored service delivery through telephonic follow-ups, ensuring timely support for members and caregivers.
• Collaborated with discharge planners and physicians to ensure effective discharge and care plan coordination.
• Assisted members in filing complaints and resolving appeals related to services.

• Counseled families facing terminal illness, offering essential emotional support and guidance.
• Conducted comprehensive assessments for patients in hospice care to identify needs.
• Developed individualized care plans addressing emotional and social requirements.
• Collaborated with interdisciplinary teams to ensure holistic patient care approaches.
• Educated families on community resources and support services to enhance coping strategies.
• Documented patient progress and interventions in electronic medical records.
• Advocated for patients' rights within healthcare systems, ensuring preferences are respected.
• Facilitated access to resources that reduced caregiver stress and improved family dynamics.

The Humana Cares Manager-Social Services (HCM-SS) proactively and telephonically assesses eligible Humana members and engage participation in Humana Cares Complex Care and Chronic Conditions Management program.

• Complete psychological, cognitive, emotional, physical, social, economic and environmental assessments, to provide appropriate and timely interventions to ensure provision for maximum care.
• Guide members and their families towards and facilitate interaction with resources appropriate for their care and well-being. Advocated for patients' rights and preferences in care decisions.
• Supported members and families by coordinating healthcare and community resources, advocating for patient rights, and facilitating referrals for medical, housing, mobility, and financial assistance.
• Used motivational interviewing to evaluate and educate members on support, motivate change and to achieve and/or maintain optimal wellness.
• Actively assist with questions and conference calls to advocate and educate members on benefits.
• Accountability: Meet established expectations and take responsibility for achieving results; encourage others to do the same; meets metrics within service level standards and ensured that all documentation is completed accurately according to state regulations.

• Supervised social work team for nursing home and assisted living facilities over three years.
• Conducted psychosocial assessments to develop tailored care plans for patients.
• Collaborated with interdisciplinary teams to coordinate comprehensive patient services.
• Managed crisis intervention and addressed emergency situations promptly.
• Monitored staff performance and conducted evaluations to promote professional growth and enhance service delivery.
• Supported MSW interns with leadership training and skill development to prepare them for clinical roles.
• Advocated for patient rights, preferences, and access to community resources.
• Implemented marketing strategies to improve quality assurance and foster family engagement.

• Interviewed residents and families to assess situations, limitations to address needs.
• Helped clients develop new coping mechanisms and techniques to drive behavior modification.
• Assisted clients with navigating and accessing social services such as housing and medical care.
• Updated client documentation for accurate, compliant and current records.
• Advocated for clients to assure respected rights and wishes.
• De-escalated stressful situations through individual and family crisis interventions.
• Supported clients and families with empathy and compassion during difficult times.
• Participated in interdisciplinary team meetings to coordinate care for residents.
• Evaluated residents' social, emotional, physical and psychological needs and developed and implemented individualized care plans for residents.