Tamatha Smith BSN RN, CCM

11/2022-current -HUMCS Triage and Support Team. 11/2016-11/2021 - Texas HSO Team.

Telephonic contact and assessment of members’ post discharge recovery at home.

Disease management and medication education for members of the Medicare population. Members have multiple medical diagnoses including but not limited to DM, CHF, COPD, HTN, ESRD, Cancer.

Collaboration with the members’ families, MDs, home health companies, hospital, and skilled nursing facility discharge planners to ensure optimal and safe recovery at home. High focus on red flag signs and symptoms, PD follow up appointments, medication accuracy, and SDOH factors.

Priority goal of reducing hospital readmission rates.

Preceptor to new case managers.

Participated in growth opportunities in addition to job which included Nurse Led Med Reconciliation study; RN and Social Worker Collaboration group, and helped to initiate a Culture Connection group.

11/2021-11/2022- Texas Population Health Stars Team-

Participated in this pilot program reaching Medicare members to focus on the highest priority HEDIS measures, and to educate about the importance of preventive care, disease management, and closing gaps in care. This pilot program had excellent results of high Stars ratings at the close of the program.

Administered Nursung Care including Oasis admissions for start of care. Skills include patient assessment, complex wound care, managing wound vacs, DM teaching and management, IV med administration, PICC line care, trach and feeding tube care, and dietary and medication education. Schedule: PRN weekends.

TRS Texas team. Telephonic complex case management.

Additionally, performed home visits to evaluate priority needs for Medicare patients’ safe and optimal recovery at home after hospital admission.

DC planning for appropriate level of care.

Disease process and medication teaching.

Collaboration with the patients, families, MD, and healthcare team to formulate a comprehensive plan to meet their preferences, specific needs, and goals in order to avoid re-admission.

Transplant/Surgical/Medical ICU

Nursing care and treatmemt of critically ill patients with a wide range of diagnoses and surgical procedures, including immediate post-operative care of liver and kidney transplant recipients.

Patient stabilization during emergency situations and codes.

Assisted MDs with bedside procedures including central/arterial line placement, GI scopes, intubation, and CVVHD management at the bedside and in the OR during liver transplantation.

Managed ICU unit (21 beds) as charge RN and precepted new RNs.

Trauma/Surgical/CV/Neuro ICU

Bedside critical care RN.

Charge RN and Preceptor for new RNs.