Laci Bach MSHS, LMSW

• Primary responsibilities include being a skilled communicator, director, and motivator; able to organize and prioritize many tasks effectively
• Meet with administration, medical director, nursing and other related departments in planning safe discharges and coordination of care
• Advocates daily on behalf of all residents to ensure that their rights are maintained
• Reports abuse, neglect or exploitation per state reporting guidelines
• Maintains professional working rapport with facility interdisciplinary team and community resources/agencies
• Educates, reviews and assists residents in completing Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate documents
• Educates / communicates with residents and/or responsible parties about Palliative Care vs
• Hospice Care and assists in the referral / transition process of residents to end of life services and end of life decision making

• Oversee complex care management for inpatient and observation-status patients, ensuring optimal outcomes.
• Initiate discharge planning upon admission to evaluate continued medical needs post-discharge from the hospital, provide resources, proactively anticipate any barriers to discharge, and coordinate post-acute care to prevent readmission.

Effectively use strong interpersonal and people skills to research, engage, and collaborate with professionals, Doctors, and liaisons within the community to coordinate post-acute care to prevent readmission.

needed, i.e., home infusions (IV ABX/TPN), skilled home health, wound care, provider services, mental health, SNF, IPR, Outpatient physical therapy.

Initiate discharge planning upon admission to evaluate continued medical needs post-discharge from the hospital using psychosocial assessment tool designed to identify barriers a patient faces in managing their medical, psychological, social, personal care and functionality.

Proactively monitor for barriers to health care, provides resources, anticipate any limitation to follow-up care post-discharge, coordinate

Advent

Stay updated on health insurance plans to ensure the best care is delivered with the least financial burden to the patient, as well at the most cost-effective avenue for the hospital and insurance plan.

Oversee complex care management for inpatient and observation-status patient, ensuring optimal outcomes.

Provide education on IMM/MOON notification and properly document to meet standards defined in Medicare guidelines.

Ensure patients' rights and choices are prioritized when recommendations are made for preferences for follow-up care at discharged.

Ensure appropriate coordination of care is in place post-hospitalization to meet the needs of each individual seeking care

• Provide education on IMM/MOON notification and proper documentation according to Medicare guidelines
• Ensure patients' rights are prioritized when recommendations are made for preferences for follow up care at discharge
• Ensure appropriate coordination of care is in place to meet the needs of each individual seeking care
• Stay updated on health insurance plans to ensure the best care is delivered with the least financial burden to the patient as well as the most cost-effective avenue for the hospital

• Conduct post- hospital follow-up phone call to new mothers who have recently discharged home from the hospital in order to promote health maintenance and member wellness
• Phone call placed within 3-5 working days of baby's birth and/or discharge from the hospital
• Remind members to schedule and attend post-partum follow up appointments within appropriate date range set by national guidelines, assist with referral to lactation consultants, provide breast pump and provide case management services for high risk pregnancies, low birth weight, and premature babies
• Assisted mothers with community resources, and support groups
• Met deadlines for compliance standards, and met cost savings goals

• High Intensity Case Manager for mentally ill consumers on Probation and or Parole
• Manage a case load size of 70+ individuals who were on completing Parole/Probation sentence through both office and home visits, lead Anger Management, men's and women Relapse Prevention, Living Skills, and Money Management therapeutic groups

• Provided case management services to clients at Martha's Home women's shelter
• Participated in Intensive Outpatient program for women at Amarillo Council on Alcoholism and Drug Abuse
• Developed curriculum for educational groups-parenting, anger management, and loss/grief
• Facilitated reminiscing group at Bivins nursing home, served as a mentor for USA program at WTAMU for first generation students; lead community service activities at Habitat for Humanity, Amarillo City Zoo