Lisa Ann Reyna-Pena,LBSW

• Completed psychosocial evaluations and needs assessments.
• Connected patients with community resources, ensuring access to essential services such as Home Health, and Durable Medical Equipment.
• Developed cultural competence through ongoing professional development opportunities, providing culturally sensitive services to diverse patient populations.
• Coordinated individualized discharge plans to manage safe transition back into community and home environments.
• Maintained detailed documentation of client progress, adhering to strict confidentiality guidelines in compliance with HIPAA regulations.
• Explained medical care options to help families make informed healthcare decisions.
• Organized clinical documentation, treatment plans, and referrals.
• Enhanced interdisciplinary team collaboration for optimal patient care through regular case conferences and communication.
• Improved patient outcomes by conducting comprehensive psychosocial assessments and developing individualized care plans.
• Supported ethical decision-making processes among healthcare teams by providing guidance on complex cases involving end-of-life care or medical ethics dilemmas.
• Educated patients on available treatment options and assisted in informed decision-making regarding their healthcare plan.
• Conducted training as a Field Instructor with University/College Internships for Interning social workers.
• Participated in interdisciplinary care conferences to discuss patient care plans and referrals.
• Coordinated patient discharge planning and follow-up care.

• Facilitated open communication between staff members, promoting teamwork and collaborative problem-solving approaches to challenges faced by clients.
• Ensured compliance with regulatory requirements by diligently monitoring policies and procedures within the department.
• Established preliminary and comprehensive assessment for social service needs of consumers.
• Increased client satisfaction by actively addressing concerns and providing timely resolutions.
• Provided crisis intervention support when needed; demonstrating empathy, compassion and resourcefulness to serve clients in times of distress.
• Constructed short- and long-term planning to improve client programs.
• Built strong partnerships with local organizations, fostering collaboration for the benefit of the community.

• Improved patient satisfaction by carefully evaluating their needs and developing personalized discharge plans.
• Advocated for patients'' best interests, working closely with healthcare providers to develop appropriate treatment plans and interventions.
• Coordinated timely discharges by effectively communicating with physicians, nurses, social workers.
• Solved problems related to abrupt changes in discharge, coordinated updates and communicated discharge plans.
• Streamlined the discharge process, reducing wait times and increasing overall efficiency within the hospital.
• Promoted a patient-centered approach to discharge planning, incorporating individual preferences and needs into the development of tailored care plans.

Consultant the following Nursing Homes: Rio Grande City Nursing and Rehabilitation-Texas, Edinburg Nursing and Rehabilitation-Texas, Windsor Arbor View-Texas, Weslaco Nursing and Rehabilitation-Texas, Brownsville Nursing and Rehabilitation-Texas, Kingsville Nursing and Rehabilitation-Texas, and Corpus Christi Nursing and Rehabilitation agencies to provide Support, Education and Clinical Review of all Social Servies systems and Activity systems.

• Evaluated program effectiveness using data-driven decision-making tools, leading to continuous improvement initiatives.
• Identified gaps in service provision and advocated for necessary resources, ensuring client needs were met effectively.
• Developed comprehensive care plans for clients, resulting in enhanced quality of life and wellbeing.
• Built strong partnerships with local University to establishing Field Training of Social Worker Students.
• Developed and maintained comprehensive client case files in accordance with organizational standards; ensured accurate documentation of services provided.
• Mentored new social workers, providing guidance on best practices and fostering a supportive work environment.
• Increased staff competency through the delivery of relevant professional development workshops and training sessions.