Paula Gianatasio

• Identified and assisted with the needs of patients including medical, social, emotional, and financial concerns through medical record review, consultation with patient, family, and healthcare team members
• Implemented innovative nursing interventions appropriate for short and long-term needs of patients
• Ensured care coordination to compliment and support medical treatment plans while integrated psychosocial, physiological, and discharge planning needs and post-discharge follow up to prevent readmission
• Coordinated healthcare services to members across continuum of care; provided follow-up for member care and evaluate outcomes
• Assisted patients with identifying their goals, values, preferences and develops care plan that aligns with patient wishes
• Provided ongoing awareness and education of Davita IKC services to providers and other teammates
• Assisted patients potentially ready to transition from active to passive treatments/intervention, including educating patients on treatment options (i.e., hospice or palliative care) and connecting them with these resources
• Collaborated with and directed the day to day responsibilities of non-clinical teammates, as required

• Made outbound calls and received inbound calls to assess member's health status
• Provided patient education to assist with self-management
• Identified gaps or barriers in treatment plans
• Made referrals to outside sources
• Provided a complete continuum of quality care through close communication with members
• Supported members with disease management, medication reviews and connections to resources
• Contacted member after post acute discharge to complete assessments and arrange for required services based on patient needs
• Followed up with case managers and clinical staff within acute are settings to facilitate patient needs upon discharge and anticipated discharge date

• Answered incoming patient calls, gathering history and symptoms to determine scope of medical complaints.
• Rendered telephone advice according to established guidelines and protocols.
• Collected data to represent symptoms, including onset, presenting problem and medical diagnoses.
• Maintained confidentiality in matters related to patient, family and client facility staff.
• Analyzed discussed symptoms with established protocols to determine patient acuity.
• Educated patients relative to health care urgency and community resources available to meet needs.
• Communicated triage information to primary care team to discuss disposition.
• Reviewed medical chart and requested appointments, prescriptions and consultations for urgent needs.
• Documented services discussed and provided details in electronic medical records.
• Cultivated professional conduct operating under triage nursing care guidelines.
• Offered medical advice and recommendations based on physician guidance and clinical protocols.
• Answered and responded to incoming calls from patients to assess patient symptoms, determine health status and identify needs.
• Documented symptoms, complaints and issues discussed during calls and actions taken in patient medical records.
• Requested direction from physicians to determine best clinical course of action and recommendations in specific patient situations.
• Scheduled same-day or first-available appointments for urgent needs by accessing provider availability in Epic and securing time slot.

• Developed appropriate care plans for at-risk individuals and high-risk families.
• Coordinated support services and optimized communication between healthcare workers and patients.
• Informed patients and families of treatment options and at-home care strategies to reduce unnecessary burden on hospital resources.
• Collaborated with various healthcare providers to facilitate delivery of services.
• Reviewed treatment plans against individual goals and healthcare standards.
• Lowered costs while improving care quality by coordinating services and collaborating with dedicated healthcare team.
• Facilitated ongoing case management services to support successful outcomes and meet stabilization goals.
• Developed comprehensive client-driven case plan with short and long-term goals.
• Protected patient data in alignment with HIPAA privacy protocols.
• Conducted assessments to obtain information for participant-centered plan of care.

Collaborated with interdisciplinary team of professionals as well as patients and families to determine appropriate treatment options.

• Gathered community resources and coordinated referrals to obtain services.
• Provided education and support to patients' family members.
• Helped patients navigate healthcare system and care options by educating on relevant subject areas and answering questions throughout treatment process.
• Communicated with relatives of patients about diagnoses and treatment programs.
• Set up family meetings with guidance from physicians.

• Listened to patients and loved ones, offering emotional support and kindness to help with end-of-life transition.
• Guided patients' loved ones and caregivers in pain management, wound care and medication dosing.
• Utilized effective interpersonal, writing and active listening skills to build and cultivate positive relationships with patients, caregivers and physicians.
• Planned hospice care for elderly and disabled patients.
• Delivered respectful, compassionate care to each patient and family through dedicated listening, kind words and empathy.
• Created and maintained facility documents and records, maintaining accuracy while managing sensitive data.
• Reviewed and assessed staff processes, reducing hazards posed for residents and staff while promoting regulatory compliance.
• Headed clinical oversight to devise and establish policies, procedures and best practices in alignment with regulatory requirements.