Assist patient’s in transitioning from an inpatient hospital admission back to primary care by providing care coordination services, home medication reconciliation, education on symptoms, reinforcement of hospital discharge instructions, and resource information. Responsible for a caseload of 20-30 patients that involved the completion of timely screening and assessments, health action care planning, and referrals to and communication with both internal service providers and community-based resources. Screenings pertained to functional abilities, daily self-management skills, level of activation, depression, anxiety, drug and alcohol use, and other screenings when indicated (examples may include PHQ-9, GAD-7, PAM/CAM, KATZ ADL, AUDIT, DAST, Pain, Fall Risk, etc.).Aligned with the Health Home six core services; Intensive Care Coordination, Health Promotion, Individual and Family Support, Care Transitions, Referral to Community Resources, and . created a health action plan setting self-management goals with the patient and helped the patient increase his/her level of activation to meet these goals.

Participated in transition of company to new owners. Worked as a 3rd shift charge nurse and provided skilled nursing care to patients in transition from hospital to their homes. Provided nursing care to long term care residents

Coordinated care for patients receiving rehabilitation and worked with multiple specialists to ensure patient continuity of care and promote positive patient outcomes.

Assistant Director of nursing services that encompasses all aspects of resident physical care, medication management and administration, and coordination of care with various disciplines.

Director of nursing services that encompasses all aspects of resident physical care, medication management and administration, and coordination of care with various disciplines.

Certified Nursing Assistant with residents living in Memory Care. I worked in this position during my nursing school education.Assisted residents with ADLs promoting dignity, purpose, and independence.

Provided intensive and strength based therapeutic mental health services and supports to children, youth and families in the home and community. Provided one-on-one supervision and assessment of safety needs. Modeled and teached appropriate social behavior and skills. Provided direct supervision and redirection of children.Worked with community partners, mental health consumers and their families using a non-judgmental approach that was timely and responsive to their individual and unique needs and concerns.