Susana Delos Reyes

• Developed and implemented comprehensive case management plans to address client needs and goals.
• Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
• Assisted clients in navigating housing, legal services and public benefits to gain access to valuable resources.
• Monitored clients' progress and tracked client services to provide crisis interventions.
• Partnered with physicians, social workers, activity therapists, nutritionists, and case managers to develop and implement individualized care plans and documented patient interactions and interventions in electronic charting systems.
• Developed comprehensive discharge plans to transition clients to appropriate service providers in community.
• Developed and implemented safety plans for clients at risk of harm to provide protection.
• Collaborated with an interdisciplinary team to determine timely delivery of services.
• Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations, and procedural costs.
• Utilized trauma-informed approach to promote healing and empowerment for clients.
• Provided evidence-based therapeutic interventions and crisis management to clients to lessen negative on physical, mental and emotional wellbeing.

• Interviewed patients to obtain medical information and measured vital signs, weight and height.
• Cleaned and sterilized medical instruments and disposed of contaminated supplies.
• Educated clients and families about rights and responsibilities.
• Advised and educated patients regarding diet, hygiene and effective disease prevention methods.
• Led multidisciplinary, continuous quality improvement program to improve patient outcomes.
• Immunized patients to protect from preventable diseases.
• Communicated with patients to understand health needs and challenges.
• Developed health plans for patients to improve overall health or recover from injuries and illnesses.

Facilitated and co-facilitated classes. REBT

Admit and discharge patients in CHCS, ALTHA, ESSENTRIS

Shift leader, to ensure mission is accomplish

• Maintained impeccable case notes and documented activities fully in CHCH ALTHA ESSENTRIS.
• Helped develop effective care plans advocated for needs of each client with outside agencies and care professionals.
• Interviewed clients, families, or groups to assess situations, limitations and issues and implement services to address needs.
• Completed detailed charts to summarize interactions with patients and booked follow-up sessions.
• Detailed residents' medical and social needs for personnel and arranged for appropriate services.
• Protected clients' health information with strict protocols focused on controlling access to confidential information.
• Transitioned residents and supporting family members to facility protocols and operational standards, answering questions and resolving problems during onboarding processes.
• Transported children and families as directed by child welfare worker or visitation coordinator.
• Conducted home visits across military housing and surrounding areas to check on patients' well-being.
• Coordinated referrals to community services to help clients obtain needed support.
• Managed residential discharges for facility and coordinated after-care activities.
• Completed comprehensive psychosocial evaluations for new residents to identify needs and strengths.
• Supported program leadership in handling day-to-day management needs of busy office.
• Explained medical care options to help families make informed healthcare decisions.
• Facilitated communication between clients and other service providers.
• Assisted in conducting needs assessments to identify key areas of service needs.
• Provided support to social service clients in navigating available resources.
• Determined needed and relevant interventions based on each client's cognitive abilities and current needs.
• Monitored progress towards service plan goals.
• Developed and maintained relationships with community organizations and agencies.
• Improved clients' coping with routine life activities such as food budgeting and rental payments.
• Cultivated and maintained relationships with community members to facilitate outreach activities.
• Developed and maintained accurate records of programs and services.
• Facilitated outreach activities to build community awareness.

• Collaborated with multidisciplinary team to evaluate patient data and determine patient care plans.
• Responded to patient emergencies to provide prompt and correct intervention .
• Administered medications and treatments to manage patient's condition.
• Utilized evidence-based practice to assess and provide care for patients.
• Educated patients and families to increase understanding of condition and best ways to manage.
• Participated in quality improvement initiatives to improve patient care outcomes.
• Maintained accurate and comprehensive patient records in line with regulatory standards.
• Demonstrated knowledge of technical procedures and proper equipment use.
• Maintained patient confidentiality by protecting unauthorized access to personal information.
• Monitored patients, evaluated results, and recommended further courses of treatment to quickly improve patient outcomes.
• Stayed current with health system initiatives and incorporated evidence-based practice and research into care routine.
• Handled patient transfers, following safety protocols to prevent injuries.
• Obtained case history and gathered triage information to determine appropriate avenue for care.
• Performed additional clinic and non-triage nurse duties such as instructing patients in general and specific medical care and health issues and administering or dispensing medication and injections.
• Counseled patients via telephone according to established guidelines and protocols, advising on provider-established plans of care.
• Scheduled appointments for patients not requiring emergency services but needing examination from provider and consulting directly with provider.
• Delivered orientation and training of less experienced clinic staff in specific clinic operations and procedures.
• Assisted in management of patient utilization of health care system and provided patient education relative to health care needs, use of community resources and responsibilities of membership in managed care.
• Monitored compliance and evaluated effectiveness of home treatment instructions.