MIRIA PRASAD PHILIP

. Provide comprehensive primary care to medically complex patients in skilled nursing and long term care settings,focusing on chronic disease management, symptoms control, and quality of life.

. Manage patients with multiple comorbidities including dementia, diabetes, COPD, CHF, and CKD stages 1 to 5, including those on hemodialysis.

. Collaborate closely with nephrologist for dialysis patient management, ensuring continuity and safety of care.

. Lead quality improvement initiatives, including a facility wide Fall Risk Analysis Program and a CHF management program, resulting in improved outcomes and reduced hospitalizations.

. Actively participate in advance care planning ( ACP) discussion with patient and families; coordinate hospice referrals and contribute to interdisciplinary team (IDT) meetings.

. Skilled electronic documentation using SigmaCare and (LWCC Live Well Care Connect) EHR systems, ensuring timely and accurate clinical records.

. Serve as clinical resource and mentor for New NPs, RNs, and LPNs on best practices in geriatric care and chronic condition management.

• Led and coordinated a CHF Management Program in collaboration with a multidisciplinary team including a cardiologist, nephrologist,dietitian, nursing staff, and palliative care.
• Conducted detailed assessments of patients with CHF, monitored fluid status, medication adherence, and lifestyle factors to prevent decompensation.
• Developed individualized care plans with a focus on diuresis management, dietary sodium control, and symptom surveillance.
• Participated in regular CHF meetings, contributing clinical input and ensuring alignment across specialties.
• Achieved zero hospitalizations due to CHF exacerbation during the program period through proactive care planning and rapid intervention.
• Educated staff, patients, families on early signs of CHF decompensation, enhancing clinical vigilance and timely response.

• Performed comprehensive physical examinations and documented patient histories to gather information and identify health issues.
• Ordered and interpreted diagnostic tests to develop and implement treatment plans.
• Prescribed and managed pharmacological and non-pharmacological treatments to treat underlying causes and relieve symptoms.
• Provided medical services and care to patients with chronic and acute conditions.
• Worked with families, caregivers and patients to determine best options for treatment, diagnosis, and prevention.
• Participated in multidisciplinary team meetings to discuss patient cases and treatment plans.
• Discussed care plans with patients and explained test results and proper use of medications.
• Educated patients on disease prevention and management strategies, promoting healthier lifestyles.
• Collaborated with interdisciplinary team members to optimize patient care and streamline processes.
• Coordinated with physicians, specialists, and other medical staff to develop treatment plans for chronic conditions.

• Delivered inpatient care in a high acuity acute rehabilitation facility, specializing in orthopedic rehabilitation, cardiac recovery, telemetry monitoring.
• Supported post -operative recovery for patients after joint replacements, cardiovascular interventions.
• Monitored cardiac telemetry, administered medications, and rehab goals in coordination with therapy teams.
• Educated patients on self care, discharge planning, and long-term recovery strategies.
• Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
• Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
• Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.
• Collaborated closely with physicians, case manager, and rehabilitation therapists to ensure holistic patient recovery.