Provided disease management, using evidence-based practices. Acted as a liaison between patient/family, medical staff, and others involved in treatment (i.e. ER, Hospitals, nursing homes, home health care, and the community at large). Focused on the needs of the patient and his/her family as she/he accessed care from the health care home. Coordinated care efforts for a safe, effective, efficient, and patient-centered transition along with the health continuum. Supported quality patient and family-centered care principles through performing a variety of high-level functions within a care team to support the needs of the healthcare team and patients/families.

Telephonic outreach to patients identified as high risk, assess health, implement plan of care with patient, follow up for further assessments and needs. educate and provide resources and referrals.

Nurse in the mother./baby unit; postpartum and nursery care.