Melanie Hammond Email and Phone Number

- Complete inpatient psycho-social evaluations to determine patients’ ability to manage transplantation and appropriate post-transplant care giver plan.- Provide case management services to organ transplant (primarily kidney) patients and families.- Build and maintain positive relationships with community and hospital liaisons.- Participate in and contribute to the documentation and chart audit committees, offering recommendation for process improvement.- Coordinate discharge planning and community referrals to include home health care, acute rehab/skilled nursing facility placement, dialysis placements and transportation.- Provide education, crisis intervention and emotional support to patients and families throughout their hospital stay.- Participate in multidisciplinary team daily rounds and work closely with physician/surgeon team, APP team, the inpatient coordinator, PT and OT and pharmacy to facilitate patients transplant care and safe discharge.- Collaborate with other healthcare professionals to develop comprehensive care plans.

- Collaborated with interdisciplinary team of professionals as well as patients and families to determine appropriate treatment options.- Coordinated psychosocial assessments, treatment plans and progress notes for pre kidney patients being evaluated for organ transplantation.- Helped patients navigate healthcare systems and care options by educating on relevant subject areas and answering questions throughout treatment process.- Identified gaps in service and appropriately connect transplant recipients pre- and post-transplant to community resources, (i.e.: housing, finance, prescription assistance, employment, transportation, mental health, and insurance) to optimize graft outcome.- Participated in community health fairs and events to educate and inform the community about transplantation and kidney donation.- Responded to hospital wide referrals for transplant education to identified patients and scheduling orientation asappropriate.

- Performed initial, 90-Day, annual, and unstable assessments for patients.- Assisted patients in locating community resources for transportation, food, prescription and insurance coverage.- Conducted In service education to staff on topics such as grievances, professionalism, communication and conflict resolution.- Educated patients about treatment modalities and transplant.- Provided counseling/therapy to patients and patients' families.- Collaborated with interdisciplinary team to provide patient centered care

- Provided effective case management of 80-100 plus dialysis patients.- Maintained appropriate documentation on all patients including monthly progress review, initial, quarterly and annual psycho-social assessments, and assess patients deemed unstable according to policy.- Gathered relevant and necessary information for patient admissions, transfers, travel and discharging patients.- Educated patients on dialysis treatment options such as transplantation, peritoneal, and home dialysis; refer as requested.- Offered referral services for patients to community resources (E.g. Transportation, medication assistance programs, secondary medical insurance, behavioral health, etc.)

- Educated patients and families on hospice philosophy during admissions process and throughout the patient stay on the program.- Assessed the psycho-social, emotional, and financial needs of terminally ill patients and their families.- Partnered with interdisciplinary team members to coordinate patient care plans by proactively identifying and appropriately addressing social and emotional factors related to the patient's care.- Helped patients and families to articulate goals of care, utilizing appropriate clinical social work treatments and interventions while maintaining the dignity of the patient.- Planned, coordinated and facilitated bereavement groups and delivered ongoing compassionate support to bereaved.

- Interviewed patients and/or family to complete psychosocial assessments and initiate treatment care plans.- Provided ongoing counseling to help patients deal with conditions and processes.- Coordinated individualized discharge plans to manage safe transition back into community and home environments.- Linked patients with community resources (i.e Medicaid, food, SSI, medications, Funeral homes, etc.)

- Assessed mental health needs to determine nature and extent of clients' emotional, behavioral or mental health issues.- Facilitated group activities (i.e. Mental illness awareness, medication management, hygiene, anger management etc.)- Documented clients' progress to keep detailed notes on each client's treatment progress and changes in mental health status.- Worked collaboratively with other mental health professionals to provide consistent care and minimize diversion.- Provided comprehensive case management services, created treatment plans, and connected clients and families to appropriate resources.

- Determine eligibility for financial, Medicaid, food stamp and child day care programs through interviews, collecting relevant verification and entering data- Develop strategies to assist recipients to become self- sufficient and independent- Consistently referred employable customers to Work First Program- Maintain case load of 150 + customers- Effectively utilize and interpret agency's manuals and policies- Prepared documents for customer appeals and presented my cases to the assigned referee