Tracey Thomas

• Served in Acute setting as Transition Care Coordinator for Bundles Payment for Care Improvement program
• Also, assisted other departments (SICC’s) within organization with follow-up Home Calls, to assist with any post SNF discharge needs
• Provided High Quality Coordinated Care, collaborating with hospital Case Managers, Physicians, Nursing Staff, Therapist (PT/OT), and Patients, with goal to help reduce Hospitalizations and unnecessary costly transitions by completing Nhpredict Assessment and running InterQual on patients that required them
• In-turn have saved Hospital Millions of dollars, while keeping patient at center
• Encouraged Patients to Manage Chronic Conditions and Promoted Preventative Lifestyles
• Provided Educational materials and information on conditions, treatment, and recovery process
• Identified needs that patient might have after leaving Acute setting and helped resolve them
• Coordinated support for Follow-up Appointments, Medications, DME Supplies, and Home Care
• Meet Market Operations Goals Yearly:
• on-site engagement with providers on 90% of Bundles cases at on-site facilities (Attend TEMPO rounds/Case Management meetings/Discharge meetings, or other discharge planning meetings per market);
• on-site engagement with patients on 75% of Bundles cases at on site facilities (review of nHPredict outcomes, engage with family members to ensure safe discharge is secured); Identify and refer appropriate patients to hospital programs, community resources and other client CM programs available in market to prevent avoidable readmissions.;
• Post discharge telephonic follow up on all patients with identified needs on Needs Assessment tool discharging from Acute to Home with 70% success rate for actual engagement
• Used company software and databases to maintain records of services performed and patient conditions
• Monitored, tracked, and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery
• Built strong relationships with clients to deliver emotional support and companionship
• Utilized electronic medical record systems to store, retrieve and process patient data.

• Team Lead and point of contact for all Clinical Inquiries
• Managing/Coordinating approximately 300+ Low, Moderate, and High-Risk Members
• Assist in Training and Orientating New Employees
• Conduct several Health-related Assessments with Enrollees and/ or their Caregiver.: Level 1(100 questions), Level Of Care Determination (at SNF facility), PCA, Etc.
• Review and Approve Services (Home Improvements, Caregivers, Etc.) based on Assessments completed by contracted Community based Organization staff
• Developed Individualized Care Plan that I periodically reviewed and updated
• Provides disease self-management and coaching
• Conducts medication review, including reconciliation during Transitions of Care Assessments
• Assess and complete Waiver eligibility packets and submit them to MDHHS
• Provides periodic monitoring of health, functional and mental status along with pain and fall screenings
• Ensured provision of services in least restrictive setting and transition support across and between specialties and care settings
• Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement
• Coordinates with social service agencies (e.g., local departments of health, social services and community-based organizations) and referral of Enrollees to state, local and/or other community resources; and
• Complete Transition of Care assessment on members that have been admitted to and discharged from hospital and/or nursing facility
• Identify potential barriers to discharge, outline needed interventions, determine members understanding of illness, and outpatient management of illness
• Coordinate with Medical Professionals and support families ensuring patient has adequate support after discharge
• Complete ICT meetings with Medical Director, Supports Coordinator (referral source), Community Health Navigator, and Member according to contract and/or based on risk level of member and/or if transition occurs
• Collaborates with nursing facilities to promote adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and coordination of services beyond scope of nursing facility benefit., Conducts assessments with Enrollees and/ or their care giver
• Develops Individualized Care Plan that is periodically reviewed and updated
• Provides disease self-management and coaching
• Conducts medication review, including reconciliation during transitions of care setting
• Provides periodic monitoring of health, functional and mental status along with pain and fall screening
• Ensures provision of services in least restrictive setting and transition support across and between specialties and care settings
• Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement
• Coordinates with social service agencies (e.g., local departments of health, social services and community-based organizations) and referral of Enrollees to state, local and/or other community resources; and
• Collaborates with nursing facilities to promote adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and coordination of services beyond scope of nursing facility benefit.

· Conducts assessments with Enrollees and/ or their care giver.

• Develops Individualized Care Plan that is periodically reviewed and updated.
• Provides disease self-management and coaching.
• Conducts medication review, including reconciliation during transitions of care setting.
• Provides periodic monitoring of health, functional and mental status along with pain and fall screening.
• Ensures provision of services in least restrictive setting and transition support across and between specialties and care settings.
• Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement.
• Coordinates with social service agencies (e.g., local departments of health, social services and community-based organizations) and referral of Enrollees to state, local and/or other community resources; and
• Collaborates with nursing facilities to promote adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and coordination of services beyond scope of nursing facility benefit.

• Complete initial assessments of patient and family to determine home care needs
• Provide complete physical assessment and history of current and previous illness(es)
• Re-evaluate patient nursing needs
• Initiate place of care and make necessary revisions as patient status and needs change
• Use health assessment data to determine nursing diagnosis
• Develop care plan, based on nursing diagnosis and include family in planning process
• Facilitate use of community resources
• Counsel patient and family in meeting nursing needs and provide health care instructions
• Identify discharge planning needs and implement prior to discharge of patient
• Prepare clinical notes and updates primary physician when necessary and at least every sixty-two days
• Communicate with physician regarding patient need and report changes in patient’s condition; obtain/receive physician’s orders as required
• Ensure that arrangements for equipment and other necessary items and services are available
• Instruct, supervise and evaluate home health aide care is provided every fourteen days.
• Developed comprehensive discharge plans to transition clients to appropriate service providers in community
• Developed and implemented comprehensive case management plans to address client needs and goals

• Consulted with resident’s physician in providing resident’s care
• Administered professional services within scope of nursing practice
• Completed all necessary charting as required in accordance with established procedures
• Supervised 20-60 residents
• Provided wound care, performed blood draws, administered medication and immunization shots
• Oriented new floor nurses, assigned tasks to employees and assessed employees’ work ethic
• Performed ongoing assessments and computer charting with Daylight IQ Coms Interactive System
• Ensured safety and sanitation standards were maintained in residents’ rooms and work areas
• Prepared and administered medication as ordered by physician in accordance with facility’s policies and procedures
• Ordered prescribed medications, supplies and equipment
• Made rounds with physicians, physician assistants and nurse practitioners
• Notified resident’s physician and/or next of ken when there was change in in resident’s condition.
• Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions
• Administered medications via oral, IV, and intramuscular injections and monitored responses
• Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans
• Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options
• Provided direct patient care, stabilized patients, and determined next course of action
• Managed care from admission to discharge
• Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols
• Updated patient charts with data such as medications to keep records current and support accurate treatments
• Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations
• Collected blood, tissue, and other laboratory specimens and prepared for lab testing
• Maintained quality care and comfort for patients with heart failure, pulmonary hypertension, and other conditions

• Administered medications, injections and routine treatments
• Performed daily blood glucose checks on adolescent client
• Implemented physician orders in accordance with agency policies
• Observed and recorded signs and symptoms of changes in client’s condition and behavior
• Provided appropriate documentation of activities and treatments.

• Brookdale Senior Assisted Living
• Managed the health, functional and psycho-social status of residents
• Performed on-site assessments of residents admitted
• Provided training, supervision, and monitored staff in the administration of medication
• Maintained resident charts and met with family members on a regular basis regarding loved ones care
• Reviewed documentation performed by care giving staff.