Nurse, Senior Staff
CurrentI was asked by Senior Management to integrate the Health Care Home Program at the Whittier clinic and was promoted from the Ambulatory Clinical Training Coordinator to the Clinical Care Coordinator for Health Care Homes.-Collaborated with faculty, residents and mid-level team of multi-specialty site with 50+ providers (FP, OB-GYN, Psych, Same Day Surgery, Alternative Medicine)-Utilized and collaborated with community resources (contracted services, hospital navigators, in-patient care coordinators, HSPHD services/programs) to ensure the patient is receiving the necessary care throughout the individualized continuum of care-Worked with MHP/Hennepin Health team to decrease the number of emergency department visits and readmissions of patients-Care planning, follow up and interventions for the patient with visits to their home, hospital, clinic or other service location-Utilized EPIC dashboard for inpatient stay reports, discharge target reports, no-show reports with documentation and chart review via EPIC-Attended Complex Case Study class for residents and presented cases for review and input-Facilitated daily huddles for interdisciplinary team of SW’s, Community Health Workers, Clinical Coordinators and Legal Aid-Involved in process improvement principles as determined by senior management. Utilized tools and methods to obtain improvement