Mary Smith

• Followed Medicare A residents from admission to discharge, providing care coordination during resident's stay.
• Coordinate and create Medicare A Care Plans, including admission and discharge care plans, and direct the meetings.
• Collaborate and communicate with Therapy Department for resident continuity of care.
• Fill in for LPN charge nurse when needed.
• Possessed excellent communication and collaboration skills.
• Performed resident treatments such as wound care as ordered by physician.
• Served as the primary point of contact, fostering strong relationships between internal teams, external partners, residents and families.

• Managed hospice patient care from admission to discharge.
• Collaborated with Interdisciplinary Team to create plan of care for patient and family to ensure positive end of life experience.
• Completed patient assessments, communicated changes with Medical director and IDT, modified plan of care as needed.
• Educated patients and families regarding patient care at end of life.
• Provided emotional support to patient and family.

• Answered after hours and weekend phone calls from patients and families.
• Over the phone, assessed patient's situation and provided instructions for symptom management and treatment as ordered by MD.
• Collaborated with local on call nurse regarding visit needs for patient and family.

• Received phone calls from patients and families from Friday to Monday and addressed their needs by phone or with patient visits.
• Addressed needs in the home in order to decrease ER visits.
• Admitted patients to hospice services
• Facilitated care coordination by maintaining thorough documentation and timely communication with all members of the interdisciplinary team.

See previous job description

• Managed end of life care for patients and families with continuous collaboration with the Interdisciplinary team to ensure excellent and compassionate end of life care.
• Provided emotional support and education to patients and families throughout their time on hospice services.
• Performed at least weekly patient assessments determined by patient condition and the needs of the family.
• Provided on call services during the week and weekends as needed.