Mary Wahl

Coordinate continuity of care from acute hospitalization to a lower level of care based upon the patient's needs to ensure the best possible outcome and appropriate utilization of community resources .

• Conduct assessments to assess patient's level of functioning and identify appropriate resources upon discharge including skilled nursing facilities,nursing homes, long term acute care , inpatient rehab, home health and hospice services.Assist with medication for self pay patients . Arrange durable medical equipment, home infusion , apply for new dialysis patients clinics and chair times.
• Collaborate with other healthcare professionals to ensure successful transition from hospital to home setting. Attend daily multidisciplinary rounds to effectively communicate on going discharge needs and barriers to discharge.
• Communicate with insurance companies to precert patients for services in the home and community. Complete mental health screening for Passr applicants .Work with office on aging for linkage to community resources and determination of choices services.

• Provided referrals to appropriate health care providers or other community resources.
• Participated in daily rounds on the cardiac floor to ensure the safest discharge plan for patients. Communicated with healthcare liaisons to place patients in short term skilled facilities or sub acute hospitals.
• Educated patients about mental health conditions, medications and self-care techniques. Arranged transfers to psychiatric facilities when patients were unable to safely discharge back to the community.
• Established professional relationships with all disciplines connected to the well being of the patient population.
• Attended Ethic conferences at UTMC, Unit council meetings and Magnet assemblies.
• Participated in professional development activities related to case management best practices.

• Met daily with physician and case manager to determine scheduled discharges. Communicated with patient and family regarding short term skilled and long term placements for patients in their community. Provided preference list with nursing homes in specific counties.
• Established relationships with admission personal in area nursing facilities to assist with patients transition to a skilled facility.
• Case load consisted of orthopedic and medical surgical patients. Worked with ortho surgeons with their elective joint patients for skilled nursing, home health and out patient therapy centers.
• Member of Joint Steering Team.Participated in Joint Commission Surveys.

• Assessed clients' needs, developed care plans and monitored progress towards goals.
• Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
• Educated client on prescription plans and assistance with obtaining plans that would lower cost of medications.
• Met with clients in their homes,assisted living facilities,nursing homes,physician offices and hospitals.
• On call with clients in crisis.
• Traveled to Knox and surrounding counties to meet clients.

• Managed admissions for a 200 dually certified nursing home facility.
• Worked with area hospitals, home health agencies and physician offices to arrange safe and efficient admissions.
• Provided emotional support and counseling to patients and families.
• Attended care plan meetings for skilled patients.
• Weekend manager every three months.