Raymon Holmes

· Displayed knowledge and understanding regarding EMR software, MDS’s and care plans.

· Performed Psychosocial Assessments and Interventions.

· Intervened with patients and families regarding emotional, social, and financial consequences of illness and/or disability.

· Participated in discharge planning activities to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers.

· Coordinated patient referrals to appropriate community social service agencies for financial assistance, employment, legal aid, or assistance in resolving other personal or family problems.

· Assured that case management progress notes are informative and descriptive of the services provided and of the residents’ response to the service.

· Attended resident visits with their PCP/specialists as needed and provides related feedback on planned interventions and outcomes of plan of care.

· Prioritized goals and develops plans based on client needs.

Participated in treatment team meetings and makes recommendations regarding treatment issues and discharge planning

· Maintained knowledge of, and demonstrates respect for patient rights.

· Designed and implemented a treatment plan of care for patients based on a thorough assessment of the patient's symptom presentation, professional/referral input and all other available data.

· Organized, developed, and directed the overall operation of the Social Services department to ensure all medically related emotional and social needs of patients were met in accordance with all applicable laws, regulations, and ethical standards.

· Maintained professional working relationships with all associates, vendors, etc.

· Maintained confidentiality of all proprietary and/or confidential information.

· Provided feedback to supervisor on an ongoing basis in regards to concerns, improvements, changes, etc.

· Acted as patient advocate and provide education to staff regarding patient rights

· Concentrated and used reasoning skills and good judgment.

· Communicated and functioned productively on an interdisciplinary team.

· Directed and supervised social service programs; evaluated the social needs of each resident admitted and formulated a written plan of care; reviewed and revised plans as necessary, not less than quarterly; referred residents and families to appropriate community resources as necessary.

· Issued Advance Beneficiary Notifications as applicable in the approved format, within the specified time frame and ensured that applicable supportive documentation were noted in the resident record

· Worked with residents on social interactions, reality orientations, and intellectual stimulations.

· Worked with families and residents on establishing and completing advance health directives.

· Completed social-care component of the Comprehensive Care Plan for each resident as identified by MDS and documented resident condition changes.

· Observed, recorded, and notified staff of changes in attitude, behavior, or personality, especially depression, anxiety, withdrawal, and uncontrollable aggression

· Compiled and recorded social histories to assist in understanding residents’ backgrounds, family problems, resources, histories of illnesses, interests, etc.

· Performed physical tasks involving transporting residents by wheelchair, lifting (20 lbs) and positioning residents (with assistance), and loading and unloading supplies.

· Participated as an active member of the Referral Development Team.