Assists in the ongoing development of policies, procedures and best practices used to amplify and enhance standardization amongst various Trinity Health at Home agencies. Responsible for supervision, oversight, and growth of daily operations of the hospital based Clinical Home Care liaisons and home based Referral Support Specialists across Michigan and California. Evaluates and analayzes various home care data reports to determine appropriate use of services, growth potential, and to capture admission data amongst our regional health ministries. Created and Facilitated Epic Hyperspace Wave 1 training for all home health liaison users across the United States

Facilitated and maintained relationships with hospital case managers to ensure a smooth home care experience while coordinating/processing referrals. Promoted fast and efficient care coordination between case managers and patients transitioning from the hospital to home.

Facilitated and coordinated extensive discharge planning needs for all patients discharging from sub acute rehab. Responsible for facilitating weekly care conferences, MDS interviews, social work assessments, and providing short term crisis intervention as needed. Lead monthly behavior management meetings with the IDT team to reduce/prevent use of unwarranted psychotropic medications.

Provided direct oversight and supervision of the social services and life enrichment department for Assisted Living, Subacute Rehab and Long Term Care. Assessed residents upon admission to identify needs and problems. Assisted residents and family members in care planning meetings to ensure each resident’s needs were met. Supported staff to ensure the needs and demand of residents were met. Educated staff on appropriate non-pharmacological interventions and appropriate behavioral management techniques. Collaborated with a behavioral management team to reduce the use of psychotropic medications. Arranged and coordinated all discharge needs. Provided counseling for residents and families and coordinated additional services as warranted. Led Town Hall meetings with assisted living staff.

Utilized clinical judgment to coordinate care management and behavioral health interventions. Identified appropriate resources available based on a comprehensive clinical assessment. Collaborated with an interdisciplinary team to ensure patients and family were involved in the patient’s care planning process. Responded to crisis situations while assessing the appropriate level of care required to meet the needs of each patient.