Paula Coccia Email and Phone Number

Primary Care Network- Rochester, NY• Manages and coordinates patients that have high risk needs or who are medicallycomplex utilizing the patient centered medical home model. • Assists with coordination of care following, ED/hospital discharge and SNFrehabilitation through follow up calls, medication reconciliation, and assessing for safeongoing plan. • Identifies patient groups with chronic diseases, provides education and resources topromote self-management skills.• Works closely with providers to identify the subgroup of high-risk patients mostamenable to hospital-avoidance programs utilizing the impactability model. • Developed and teaches ongoing diabetes and weight loss classes. • Communicates effectively with physicians, the home care team, patients, and theircaregivers.

Manage patient care in a team approach with NP, residents and attending providers. Telephone triage, coordination of anticoagulation therapies, management of controlledsubstances. • Assist providers within the clinic with treatments, immunizations, patient riskscreens.• Coordinate and communicate between providers to manage difficult patients and establishsafe plans of care.

* Recieves,manages and triages clinical infromation from physician offices, nursing homes, EMT's and Mercy Flight. * Answers and facilitates medic phone and relays information per protocals* Facilitates and coordinates inpatient transfers from outlying hospitals to Strong Memorial

Clinical Review Specialist detemining appropriate Level of Care and Severity of Illness* Coordinate and collaborate with Interdisciplinary team for safe hospital discharge* Communicate with providers to ensure optimal clinical documentation* Maximize appropriate available resources for continuity of care.Home Care Liaison Full time and Per Diem/Weekends Coordinates and arranges discharge for patients referred. Evals for safe discharge plan and arranges for any vendor/DME teaching /support PRI and Screens for patients identified for Skilled Nursing Rehab or LTC.

Managed Case Load of Patients with skilled needs following hospital discharge and those with chronic conditionsAdmissions Nurse / Oasis Medication ReconciliationEducation and teaching for all systems related to acute or chronic conditionAssessment and evaluation of safe home plan and long term planning