Maria D. Alegre

• Started initially by performing post discharge follow up calls on patients hospitalized and discharged from Non-Kaiser Foundation Hospitals in collaboration with KP Reconnect. Then transitioned to performing post discharge follow up calls on patients hospitalized and discharged from Kaiser Baldwin Park Medical Center with discharge LACE SCORES of 11 and above, patients (both Kaiser Members and Non-Members) with primary or secondary diagnosis of Acute Heart Failure Exacerbation regardless of LACE Scores. Provides care coordination and outpatient case manager needs to patients called. Collaborates with the Primary Care Team, Rounding Hospitalists, Specialty Teams, Care Without Delay Physicians, Utilization Management Team, Home Health/Palliative Care/Hospice Care Departments, Durable Medical Equipment and other disciplines such Physical Therapists, Wound Care Nurses, Dieticians, Speech Therapists, Occupational Therapists to assure that patients transition to home seamlessly by ensuring that patients are discharged with appropriate resources and referrals for follow

up.

• Member of Utilization Management Department's Unit-Based Team.
• Assists with facilitation and preparation of the PowerPoint Presentation for the monthly Hospital Readmission Committee Meeting.
• Collaborates with the Regional Readmission Committee in improving Readmission O/E (Observed over Expected) Ratio.
• Member of the team that provides education/training/assistance to In-Patient Ward Clerks on scheduling POSH (Post Hospital) Appointments within 7 days of discharge as part of the Regional Readmission Goals.
• Collaborates with outpatient Primary Clinics to ensure that POSH Scheduling and Completion Goals are met.
• Utilization Management representative for the Wellbeing Mobility Program (Frailty Collaboration Across the Continuum) until end of 2023. Provided staff education and training on Wellbeing Kit provision to patients on discharge and was responsible with creation of Case Manager's workflow.
• Works with leadership and staff to implement new programs/projects in the Department.

RN Case Manager:

• Collaborates with physicians, other members of the multidisciplinary health care team & patient/family with discharge planning needs to ensure continuity, quality & appropriate resource use. Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential services are delivered timely and efficiently.

Bed Coordinator:

• Coordinates the assignment of patient care beds within the hospital. Performs initial admission screens to assure patient admissions and bed assignments are appropriate. Works in collaboration with multiple departments within the hospital and facilitates regularly scheduled bed management meetings to identify and communicate bed utilization issues. Identifies and reports barriers to patient throughput.

RN Case Manager:

• Collaborates with physicians, other members of the multidisciplinary health care team & patient/family with discharge planning needs to ensure continuity, quality & appropriate resource use. Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential services are delivered timely and efficiently.

Bed Coordinator:

• Coordinates the assignment of patient care beds within the hospital. Performs initial admission screens to assure patient admissions and bed assignments are appropriate. Works in collaboration with multiple departments within the hospital and facilitates regularly scheduled bed management meetings to identify and communicate bed utilization issues. Identifies and reports barriers to patient throughput.

• Provided safe and effective nursing care to all patients utilizing the nursing process. Responsible for the direction and supervision of assigned personnel delivering said patient care.
• Optimized resource allocation by analyzing daily acuity levels and adjusting staffing assignments accordingly.

• Managed critical care patients with complex medical conditions, providing compassionate care and support to families.
• Conducted ongoing monitoring of vital signs, lab results, and diagnostic tests to promptly identify changes in patient conditions.
• Monitored patients' respiratory status and ventilator operation and made adjustments to promote stabilization.
• Provided life-saving interventions during emergency situations, stabilizing patients and preventing further complications.
• Collaborated with multidisciplinary teams to develop individualized care plans for optimal patient recovery.
• Delivered age-appropriate medical care for adult, adolescent, and geriatric ICU patients.