Deborah Rockefeller Email & Phone Number

* Effectively Case Manage 40 medically-compromised patients with the ability to accept additional cases as needed ; * Assess the unique patient and family needs, coordinate services, and link & refer patients to the most appropriate and available resources ; * Collaborate with Certified Home Health Agency (CHHA) staff, such as Nurses, Physicians, and Physical & Occupational Therapists to effectively meet patient needs ; * Interact with, refer, and coordinate care to a wide range of agencies (Office of the Aging, Department of Social Services, Adult and Child Protective Service, Meals on Wheels, Department of Veterans Affairs) and waivered programs (Nursing Home Transition Diversion (NHTD), Medicaid, Traumatic Brain Injury (TBI), Managed Long Term Care (MLTC)) ; * Assist patients and families with long term planning and community resource needs ; * Maintain extensive knowledge of community resources to meet patient needs and make appropriate referrals ; * Empower patients and families by enabling them to identify & understand options, and make informed decisions ; * Beyond the duties of a Medical Social Worker, provide follow up to patients and families to ensure needs are met including assistance with paperwork, forms, fielding insurance-related questions, and phone calls to ensure necessary connections are successful ; * Provide Hospice Social Worker assistance through home comfort care referrals and offering emotional support ; * Actively participate in Interdisciplinary Team (IDT) and Interdisciplinary Group (IDG) activities to ensure the delivery of the most robust care to the patients ; * Valid and active use of Screen Certification ;

* Successfully managed two program sites with direct responsibilities of 17 Service Coordinator ; * Effectively carried out all departmental operation responsibilities including but not limited to responding to multiple consumer emergencies, reviewing and signing off on all incidents, addressing staff needs and concerns, and complex problem solving ; * Responsible for all staffing related matters including but not limited to interviewing, screening, hiring, disciplinary actions, yearly evaluations, monthly supervisions, monthly department meetings, and department financials ; * Read and reviewed case notes, approved Individual Service Plans and Revised Service Plans ; * Served as a liaison between Service Coordinators and partner agencies, Developmental Disabilities Services Office, Office of Mental Retardation and Developmental Disabilities, Department of Health, and private entities ; * Member of the Adult Management team, Agency Management team, and Agency Incident review committee ;