Summary: Transitional Care Manager

Follows efficient, logical sequence; balances screening/diagnostic steps for problem; informs patient; sensitive to patient’s comfort, modesty.

i. Does the patient need to use the restroom, urinal or ambulate to bathroom and if so, assist them to prevent falls and stay with them until completed

From a business aspect, she orders and maintains supplies; coordinates the ICD 10 coding; manages patients’ accounts as patients’ risk level changes, cardiac/pulmonary rehab phase changes, or if patients have a personal or medical leave of absence. She schedules patients sessions to

ability of patients and assist them if needed to ensure the quality and hygiene of all patients. With

They are able to perform patient care by IV and oral medication administration, cardiac monitoring, airway management, blood transfusion, wound care etc… They are accountable to implement family central patient care.

• Coordinate with physician and nursing staff to address the patient’s prognosis, treatment, and care plan.

Facilitator: Assess potential patient discharge barriers, Encourage post-discharge support(Family/friend) and promote early patient involvement during the discharge planning process( discharge education, health care education, post-discharge care)

Followed the supervising physician manage patients in the Critical Care Unit, including patients on ventilation support. Acquired clinical expertise in the management of critical cases like Cerebrovascular Accident, Pneumonia and para-pneumonic effusion, acute and chronic renal failure, and dialysis, Chronic obstructive pulmonary disease and non invasive positive pressure ventilation, obstructive sleep apnea and use of continuous positive airway pressure. Took patient histories, performed physical examinations under supervision and participated in case discussions. Gained practical experience in the use of EpicCare electronic medical records system and effectively entered assessment and management plans for my supervising physician. This rotation

patients are taken care of and that the doctors are being informed of any changes with the patient.

We provide clear, effective, and timely communication and education to help the patient and family understand their condition and treatment

Once a patient is diagnosed at the primary care physician’s office, the dedicated staff member could begin to coordinate care for this patient. The staff member can make sure that there are adequate follow up visits after the diagnosis is made, they can be sure that the patient is taking their medications on a regular basis if they need medications, the staff member can also coordinate with the healthcare team to keep them updated on the patient’s status.

Discharge Planning – Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.

As Branch Manager I am responsible for streamlining business operations and instituting measures to improve care. Other managerial duties include analyzing business processes, creating and reviewing budgets, coordinating with other managers, and assessing business performance. Additionally, as a Branch Manager I am responsible for creating schedules, evaluating personnel, and conducting performance reviews. When patients are admitted, I communicate with them to assess their needs and then consult with other health professionals to decide on which services to provide and contact insurance companies to determine a patient's plan coverage. Inform patients regarding general preventative care practices as well as individualized care plans. Keep

C. Coordinator: Many patients do not have the ability to keep track of all doctor visits, prescription refills, appointments, etc. The nurses will schedule doctor visits while at the patient’s home to ensure the patient is receiving referred care if needed. It is no guarantee that the patient’s will schedule appointments that are needed, therefore the nurses may take matters into their own hands and schedule appointments to make sure things are getting done, rather than relying on the patient to make it happen, of course with the consent of the patient to do so.

(complete Within first 14 days initial evaluation and assessment form on the basis of interviews and review with resident, family, friends, medical records., sub-acute assessment by disciplines specific to the admitting diagnosis is initiated in 24-48 hrs including medical., completes periodic MDS updates, within 7 days of the completion of the initial MDS, but no later than 21 days after admission, records social service problems, goals and approaches in the overall resident care plan. Writes Social services progress notes as necessary and quarterly notes as required by regulatory agencies. Documents initial discharge plan