Toma Horton

• Conducted patient assessments and identified health risks.
• Provided education to patients on self-management of chronic conditions.
• Coordinated with physicians, nurses, and other healthcare providers to ensure continuity of care.
• Monitored and evaluated patient outcomes in order to improve quality of care.
• Assisted with the coordination of post-discharge services such as home health care visits or community resources.
• Collaborated with case managers, discharge planners, social workers, and other team members to facilitate transitions between levels of care.
• Educated families on disease processes and treatment options available to their loved ones.
• Identified potential barriers that may impact a patient's ability to comply with prescribed medical regimens.
• Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
• Referred patients to specialized health resources or community agencies to furnish additional assistance.

• Explained policies, procedures and services to patients.
• Demonstrated self-reliance by meeting and exceeding workflow needs.
• Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.
• Received patient inquiries or complaints and directed to appropriate Service Office staff
• Helped patients obtain health care services such as Skilled Nursing, Physical Therapy, Speech Therapy Occupational Therapy, and Medical Social Worker by identifying the need for services based upon assessment, diagnosis and the skilled need related to home care, ultimately completing and setting up referrals.
• Recently Spearheaded Education/Virtual Training Session of New Infinity Enteral Pump Training to Improve Staff proficiency in educating family members of the Pediatric population prior to discharge
• Collaboration with Hospitalist, inpatient Care Management team and Manager, PCP office staff and Service office scheduler to ensure adequate referral completion.
• Communication via High Risk Conference Calls with Leadership to determine appropriate Level of Care and or Action Plan
• Resourceful, accessible and reliable to peers and other team members of the South Team including Christ Hospital, Trinity Hospital and South Suburban Hospital Liaisons, by assisting to troubleshooting and resolving work related challenges and processes routinely

Quality Review Nurse

Assessed Home Care Disciplines Plan of Care/485 for accuracy, prior to releasing to medical doctor for signature.

Coordinated with Clinical Managers and multidisciplinary team members to assure that charting corrections were performed in a timely manner.

Clinical Coordinator

Learned to Properly identify Face to Face Encounter Documentation of Hospitalized patient, Ambulatory Care Patients and inpatient of a Skilled Nursing Facility as ordered by Referring Physician, Nurse Practitioner and or Clinical Nurse Practitioner.

Identify Supporting Documentation including, vitals, labs, therapy recommendations,

including Criteria One and Criteria Two as related to Homebound status Requirements for Skilled Home Care Services.

Referral Intake Liaison

Collaborated with MD office, Hospitals and Skilled Nursing Facilities to facilitate smooth transition from the acute care and skilled nursing facilities to Advocate at Home by completing appropriated and timely Referrals.

Responsible for keeping Manager informed of status at assigned facilities.

Completes final assessment on complex referrals involving infusion therapies, complex wounds and/or enteral feedings

Provided High Level Skilled Nursing home care services to the homebound patient.

Identified Learning needs of the patient and or Care Giver, facilitating independence with managing their illness post hospitalization, thereby reducing Rehospitalization

Responsible for effectively Case Managing 25-35 patients in the assigned territory.

Coordinated Medical Care by identifying Utilizing other disciplinarians such as PT/OT/SLP/MSW after obtaining md order.

Collaborated with Outpatient clinics such as Wound Care, LVAD, CHF and Coumadin Clinics, reporting patient condition/status changes, lab values, obtaining and carrying out md orders.

• Monitored post-op vitals, set up PCA, fluids, reviewed post-op orders and assimilated patients to unit.
• Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
• Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
• Executed appropriate steps for patient treatment following careful review of physician medical regimen.
• Treated patients using pharmacological and non-pharmacological treatment modalities to address various disorders, diseases and injuries.
• Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
• Participated in continuing education programs recommended workshops to enhance training and nursing knowledge.
• Trained and mentored new RNs on best practices, hospital policies and standards of care.
• Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
• Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
• Coordinated with healthcare team to establish, enact and evaluate patient care plans.
• Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
• Documented all therapies, including Weight Based Heparin, IV Insulin Therapy, TPN, Enteral Feedings and more while keeping patient charts up-to-date.
• Communicated with primary care physicians or emergency care providers to relay patient needs.
• Complete Admissions and Discharges while actively participating in discharge planning and education
• Acted in role as Charge Nurse, supervising up to 11 nurses on a 42 bed unit effectively.
• Provided Care to Care and Education to Ventilator Assisted Patients