Teresa Smith
Corpus Christi,TX
Summary
Highly skilled professional with practical experience of 15+ years in Med/Surg, Home Health and Hospice clinical settings. Critical thinking skills essential to providing competent and dignified patient care. Advanced organizational, interpersonal, and communication skills. Confident decision maker with the experience to remain calm and make quality decisions in demanding situations.
Overview
15
15
years of professional experience
1
1
Certification
Work History
RNCM
CoreMedical Staffing
Manchester, NH
05.2023 - Current
- Provide at-home, patient-centered care for those meeting the end of life criteria as determined by the CMS.
- Develop and maintain patient-centered care plans derived from clinical assessment and nursing diagnosis.
- Collaborate with the interdisciplinary care team to develop a fully integrated plan of care that meets the patient's holistic needs.
- Implement interventions that support the physical, emotional, and spiritual health and well-being of the patient and family.
- Offer patient/family emotional support and education on disease process and interventions used to ensure comfort.
- Document patient notes electronically within company-required timeline.
Hospice RNCM/PRN Nurse
OpusCare Hospice
Corpus Christi, TX
08.2020 - Current
- Provide at-home, patient-centered care for those determined to be at the end of life.
- Develop and maintain patient-centered care plans derived from clinical assessment and nursing diagnosis.
- Collaborate with the care team to develop a fully integrated POC that meets the patient's holistic needs.
- Implement interventions that support the physical, emotional, and spiritual health and well-being of the patient/family.
- Provide patient/family emotional support, and instruction on disease processes and interventions used to ensure patient comfort.
- Document patient notes electronically within company-required timeline.
Hospice RNCM
Transcend Hospice
San Antonio, TX
10.2019 - 12.2020
- Provided at-home patient-centered care for those meeting end of life criteria.
- Developed patient nursing diagnosis and individualized care plans derived from clinical assessments.
- Collaborated with the care team to develop a fully integrated plan of care that met the patient's needs.
- Implemented identified interventions to ensure patient physical, emotional, and spiritual needs were met throughout transitioning phases of life.
- Documented patient notes electronically within company-required timeline.
Hospice RN Case Manager
New Century Hospice
Corpus Christi, TX
12.2019 - 08.2020
- Provide at-home, patient-centered care for those determined to be at the end of life.
- Develop and maintain patient-centered care plans derived from clinical assessment and nursing diagnosis.
- Collaborate with the care team to develop a fully integrated POC that meets the patient's holistic needs.
- Implement interventions to support the physical, emotional, and spiritual health and well-being of the patient/family.
- Communicated regularly with family members regarding patient care needs and progress toward goals.
- Document patient notes electronically within company-required timeline.
RN CARE MANAGER
Centene Superior Health Plan
San Antonio, TX
10.2018 - 10.2019
- Performed assessments, planning, and coordination of all aspects of medical and supporting services across the continuum of care for Medicaid members to promote quality, cost-effective care.
- Assessed the member's health status, resource utilization, treatment plans and services, prognosis, short and long-term goals, treatment, and provider options.
- Identified barriers and service coordination needs.
- Coordinated all services needed by member to ensure safety and assisted in maintaining and/or improving member's current health status.
- Evaluated if services in place were effective and meeting the needs of members.
HOME HEALTH RN CASE MANAGER
Sunbelt Staffing LLC
03.2018 - 09.2018
- Provided at-home patient centered care, for those with complex medical conditions.
- Developed and maintained individualized care plans derived from clinical assessment and nursing diagnosis.
- Performed identified interventions as ordered. i.e. wound care, ostomy and/or Foley catheter care, medication administration, tracheostomy care, and peg tube feedings.
- Collaborated with an interdisciplinary care team to develop treatment plans that met the needs of each patient.
- Ensured compliance with applicable regulatory standards related to home health services.
RN COMPLEX CASE MANAGER
Molina Healthcare
San Diego, CA
08.2014 - 01.2018
- Managed 60-80 complex cases involving patients with multiple hospitalizations and diagnoses.
- Collaborated with interdisciplinary care team to identify barriers to health care needs and plan post-hospitalization home care, in order to prevent re-hospitalization.
- Monitored and managed various treatment and care interventions.
- Acted as patient advocate and implemented total patient care through team nursing process.
- Advocated for patients by supporting and respecting basic rights, values, and beliefs.
RN HOME HEALTH SUPERVISOR
Warm Heart Home Health
El Cajon, CA
11.2013 - 05.2014
- Held responsibility for the supervision and direct oversight of a clinical team providing services to patients of DBA Shea Family
- Ensured initial patient contact within 24 hours of referral to determine patient meets standards of care for services
- Maintained compliance with applicable laws, state, and federal regulations and company's standards, policies and procedures as it related to patient care
- Assisted company in successfully obtaining JCAHO certification
- Managed efficient utilization of all resources including, but not limited to, materials/supplies, equipment, time, dollars and FTE
- Investigated problems, grievances and complaints and took corrective action when appropriate
HOME HEALTH RN
Gentiva Home Health Services
San Diego, CA
04.2012 - 11.2013
- Provided at-home individualized patient care, treatment, health assessments, and clinical documentation for geriatric and adult patients
- Coordinate plan of care and maintain continuity of client care with other health professionals
- Identified interdisciplinary care needs and made recommendations for additional home health care services
- Provided physical and emotional comfort while developing and encouraging patient independence
HOME HEALTH RN
Dependable Home Health
Tucson, AZ
11.2011 - 04.2012
- Provided at-home, one-on-one patient care for patients with chronic and complex medical conditions.
- Developed patient-centered care plans, derived from clinical assessment and nursing diagnosis.
- Implemented identified interventions as ordered to ensure the best possible patient outcomes.
- Assessed patient progress and effectiveness of care delivery in meeting patient goals.
RN MED/SURG
St. Joseph's Hospital/Ascension
Tucson, AZ
08.2009 - 09.2011
- Held responsibility for daily pre and post-surgical physical assessment, preparation, and documentation of med/surg/psychiatric adult inpatients
- Scheduled and coded patient surgeries, tests, and procedures
- Developed long-term care and discharge care plans and made referrals for additional support services
- Safely monitored patients, administered medication, provided discharge instructional education to patients and caregivers with a focus on proper use of equipment, safety, infection control, and pain management
- Acted as clinical resource to support staff
Education
Associate of Science - Nursing
Pima Community College
Tucson, AZ05-2009
Bachelor of Science - Health Services, Worksite Wellness and Health Promotion
University of Southern Indiana
Evansville, IN05.2004
Skills
- Complex Case management
- Care Coordination
- Patient Education
- Critical Thinking
- Clinical Assessments
- Nursing Diagnosis
- Care Planning
- Nursing Intervention/Evaluation
- Flexible and Adaptable
- Self-Directed
- Teamwork and Collaboration
- Friendly, Positive Attitude
- Task Prioritization
- Compassionate Care
Certification
- Registered Nurse, Texas Compact State - 1008405. Current
- Certified Health Coach
Personal Information
- Title: Registered Nurse
- Work Permit: Authorized to work in the US for any employer
References
References available upon request.
Timeline
RNCM
CoreMedical Staffing
05.2023 - Current
Hospice RNCM/PRN Nurse
OpusCare Hospice
08.2020 - Current
Hospice RN Case Manager
New Century Hospice
12.2019 - 08.2020
Hospice RNCM
Transcend Hospice
10.2019 - 12.2020
RN CARE MANAGER
Centene Superior Health Plan
10.2018 - 10.2019
HOME HEALTH RN CASE MANAGER
Sunbelt Staffing LLC
03.2018 - 09.2018
RN COMPLEX CASE MANAGER
Molina Healthcare
08.2014 - 01.2018
RN HOME HEALTH SUPERVISOR
Warm Heart Home Health
11.2013 - 05.2014
HOME HEALTH RN
Gentiva Home Health Services
04.2012 - 11.2013
HOME HEALTH RN
Dependable Home Health
11.2011 - 04.2012
RN MED/SURG
St. Joseph's Hospital/Ascension
08.2009 - 09.2011
Associate of Science - Nursing
Pima Community College
Bachelor of Science - Health Services, Worksite Wellness and Health Promotion
University of Southern Indiana
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