Self-motivated, hardworking Social Worker offering a diverse history of experience working in different health care settings supporting overall needs for individuals and families. I offer documented success in overcoming complex challenges while working with patients, families and multidisciplinary professionals to provide needed resources and services to individuals in our communities.
Overview
4
4
years of professional experience
Work History
Transitional Care LSW
Health Partners
10.2022 - Current
Refer clients to appropriate team members, community agencies and organizations to meet treatment needs.
Coordinate specialized care services such as spiritual care, mental health supports, hospice, and/or palliative care when indicated based on individual patient needs and preferences.Improve patient outcomes by developing and implementing personalized transitional care plans.
Reduce hospital readmissions by identifying high-risk patients and providing targeted interventions.
Facilitate seamless transitions between healthcare settings, ensuring appropriate care and follow-up appointments.
Collaborate with interdisciplinary teams to evaluate and address the physical, emotional, and social needs of patients during transitions of care.
Med-Surg, ICU, ED, & Mental Health LSW
Allina Health
04.2022 - 01.2023
Implemented social service interventions to achieve treatment goals and assess patients basics needs being met, such as; food, housing, transportation, medical services, etc
Educated patients and caregivers on community resources and post-acute level of care criteria, benefits and coverage
Identified and addressed financial and emotional barriers to discharge and recovery
Collaborated with interdisciplinary team of professionals as well as patients and families to determine appropriate treatment options
Interviewed clients individually and in family groups to determine services to best address specific needs
Arranged for medical, mental health or substance abuse treatment services according to individual needs or court orders
Helped patients navigate healthcare system and care options by educating on relevant subject areas and answering questions throughout treatment process
Communicated with patients and families about diagnoses, treatment programs, and health care team recommendations
Set up family meetings by coordinating with interdisciplinary team members, families, and appropriate county members if applicable.
Post Acute Director of Social Services
Benedictine Living Community Owatonna
02.2020 - 04.2022
Assessing and implementing social service care plans to best meet the needs and goals of residents overall planning
Completing admission intakes and discharge planning for individuals in transitional care units at SNF
Providing leadership to a multidisciplinary team and working effectively in a team setting
Working and collaborating with community agencies, county team members and additional support members to assist residents current and possible future needs for placement and supports
Obtaining and maintaining thorough social history records, trauma informed screenings and effectively writing detailed case notes
Responsible for identifying and reporting Vulnerable Adult Reports and conducting appropriate investigation with involved parties to ensure resident safety
Developing workable solutions for recurring problems for individuals and families while also providing them with services to best address their specific needs
Educating, and preparing residents for transition to independent living, ALF, SNF, group home, or other planned housing placement
Informing families of hospice, grief and bereavement resources
Assisting individuals and families that are uninsured or under-insured obtain additional county services and fundings to meet their needs
Participate in discussions with multidisciplinary teams for collaboration and coordination of residents needs
Providing education and resources to residents and families to assist in safe discharge planning needs
Conducting needed assessments to support individuals psychosocial wellbeing such as BIMS, PHQ-9, GAD, Social History, Trauma, Elopement Risk, etc
Scheduling and facilitating initial, quarterly, annual, and discharge care conferences.
Mental Health Rehabilitation Worker
Cedar House Life Change Center
08.2019 - 02.2020
Creating client treatment plans based on assessments and goals
Adhering to HIPAA confidentiality requirements by safeguarding files
Referring clients to external resources for additional support
Facilitating supportive and psychotherapy services to address needs of clients 18 years and older Documenting daily notes and notifying appropriate parties of concerns for overall health changes
Working in a multidisciplinary team setting
Conducting initial intake assessments, quarterly assessments and annual assessments Providing social services to clients Providing and/or setting up transportations for clients Ensuring safety of clients Created client treatment plans based on assessments and goals.
Education
Bachelor of Science in Social Work -
Minnesota State University - Mankato
12.2018
High School Diploma -
Technichal High School
05.2014
Skills
Critical Thinking
Motivated in Fast Paced Work Environments
Patient Advocacy and Rights
Problem Solving and Resolution
Team Collaboration
Coaching/ Educating Patients, Families, etc
Conducting assessments and providing appropriate recommendations for resources and services
Knowledgeable in Health Insurance Plans, Benefits, Eligibility, and Enrollment process for uninsured or underinsured individuals
Rehabilitation / TCU Planning
End of Life / Palliative Care / Hospice Care Planning