Palmire Thomas

• Completing psychosocial assessments and discharge planning evaluations, clearly documenting findings, and communicating needs across the care team.

• Collaborating closely with the Rehab Program Director, Facility Case Management Director, and interdisciplinary team to ensure seamless, patient-centered care.

• Developing and implementing individualized treatment plans that reflect the patient’s strengths, needs, and personal recovery goals.

• Provide timely and accurate completion of the Social Services portion of the MDS, Resident Assessment Protocols, Resident Care Plan, and Progress Notes, as well as the Social Services Assessment, and other forms as required by the Administrator to comply with federal and state regulations, and facility policies and procedures.
• Maintain progress notes for each resident as required by company policy, as well as state and federal regulations, indicating the response to the treatment plan and adjustments to facility life. Progress notes shall be recorded on the appropriate form and placed on the resident’s chart, in compliance with state and federal regulations. Progress notes must reflect the progress made regarding the problems identified in the Plan of Care.
• Participate in the development of discharge plans, as appropriate, and prepare the resident for transition.
• Visit residents and perform needed services, such as communicating with the family or friends, utilizing community resources, and informing the resident and/or legal representative of the Residents' Rights.
• Coordinate logistics and content for monthly Family Council Meetings.
• Coordinate resident room changes.
• Contact the resident or legal representative, and invite them to care plan meetings to participate in the evaluation of the resident.
• Maintain contact with the resident, legal representative, and other family members approved by the resident or legal representative, involving them in the resident’s total care, and providing them with information on the resident’s status as requested or appropriate.
• Work with the Activity Coordinator on providing requested effects for residents who do not have family support.
• Promote favorable working conditions and relationships with the administration, medical staff, physicians, consultants, other departments, residents, family members, volunteers, agencies, and any other individuals or groups affiliated with the facility.
• Work closely with the facility's mental health provider to ensure that all residents' psychosocial needs are identified, referrals are made, and services are provided.
• Orient the resident to the long-term care environment and facilitate adjustment upon placement.

• Non profit organization
• Responsible for the direction, and support of Home Health sales and operations
• Develops, maintains and strengthens business partnerships (Hospital Systems, Physicians, SNFs, ALFs, ILFs, Hospice, Outpatient, Ancillary, ACOs, BPCI, and C-Suite Executives) for the Organization’s core businesses in Palm Beach County
• Provides leadership and direction of start-up operations for Home Health Agency
• Provides oversight of P&L targeting for developing and progressing to profitable operations
• Responsible for the development and implementation of strategic business plans for Home Health Services (sales/marketing and operations)
• Identifies and attains overall census growth targets in Palm Beach County
• Collaborates with leadership, sales, marketing, and operations to secure, retain and grow strategic partnerships Medicare/Private Duty Home Health Sales, Account Manager, and Business Development experience.

• Develop a strong relationship with the hospital case managers, discharge planners, and social workers.
• Develop and maintain strong relationships with area ALFs, home health agencies, retirement communities, and senior centers.
• Develop and maintain strong relationships with local physicians, ensuring effective communication. Recruit new physicians to serve as attending physicians for residents in the facility.
• Assist the physician in completing the company credentialing process if they wish to be a facility-attending physician.
• Review and assess prospective residents by reviewing their medical, physical, and psychosocial needs, and obtain, in conjunction with the Call Center Coordinator, Internal Admissions Coordinator, and nursing team, a decision for admission within a 15-minute guideline utilizing the center's customized Green-Yellow-Red Light Tool.

• Perform case management duties to assure the necessity of patient admissions and the appropriateness of continued stay.
• Assess, implement, plan, and evaluate the needs of patients for discharge planning.
• Works closely with interdisciplinary staff to ensure a safe discharge plan.
• Coordinated and provided supportive counseling to patients diagnosed with cancer and their families.
• Coordinate hospice and palliative care for end-of-life cases.
• Arrange rehab placement or home health care for patients.
• Assist with disability applications and follow up.
• Nicu, Labor and Delivery, Postpartum.
• Coordinated support services and optimized communication between healthcare workers and patients.
• Transitioned clients to different providers based on progress or needs.
• Reviewed treatment plans against individual goals and healthcare standards.

• Assess and evaluate the patient in the home setting.
• Provide patients, individuals, families, and/or caregivers with the psychosocial support needed to cope with chronic, acute, or terminal illnesses.
• Provide patients with information, counseling, and make referrals for other services.
• May also provide case and/or care management, or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.
• Advocate for clients or patients to resolve crises.
• Refer the patient, client, or family to community resources to assist in recovery from mental or physical illness, and to provide access to services such as financial assistance, legal aid, housing, job placement, or education.
• Communicating with people outside the organization, representing the organization to customers, the public, the government, and other external sources. This information can be exchanged in person, in writing, by telephone, or by email.
• Communicate and coordinate with the nurse, therapist, case manager, and director of nursing regarding patient issues and concerns.