Care Coordination Disease Management Educator

SILVIA D. DEVESCOVI, RN, BSN

**** ********* ***** ****, ** 89523 775-***-**** *********@*****.***

CARE COORDINATION

DISEASE MANAGEMENT EDUCATOR

Expert CLINICAL CARE COORDINATOR with combined expertise as DISEASE

MANAGEMENT EDUCATOR empowers patients to achieve their health status goals.

Through a telehealth model, maximizes nursing care and exposure to patients

by coaching patients across a wide variety of chronic health issues.

Minimizes costs for hospitals, physician practices and health care insurers

with deep insight into rapid and simultaneous changes in the health care

marketplace. Powerfully, builds on longstanding expertise in acute care

clinical nursing and tertiary care clinical nursing, plus broad nursing

management experience in modern telepresence care coordination strategy.

Clinical Care Coordination and Disease Management Care Coordinator /

Educator Expertise:

Registered Nurse Clinical Assessment Disease Self-Management Patient

Tracking Telephonic Contact

Quality Management Motivational Interviewing Patient-Centered Health

Care

NCQA URAC JCAHO

Clinical Nursing and Clinical Nurse Management Expertise:

Acute Care Tertiary Care Triage Trauma Chronic Disease Management

Preventive Medicine Transitional Care Team Leadership Coaching

Mentoring Training Clinical Teaching Resource Allocation

Large Team Leadership Process Improvement Cost Management Revenue

Capture

Emergency Nursing Occupational Health Nursing Geriatric Nursing

Cardiac Pulmonary Diabetes Depression Arthritis Chronic Pain

Management

Telecommuter Health Coach Consultant Telecommuter Clinical Care Manager

2006 - Present

Consultant and Care Coordination Educator, Reno, NV American Health

Holding, Inc. (Aetna), Reno, NV

Hometown Health Plan, Reno, NV Alere, Reno NV

In response to modernizing demands of a new health care environment

established an extensive knowledge base in health care coordination, and

disease management model for patients, physicians and the interprofessional

team. Provided care coordination expertise in multiple organizations,

refining strategy and preparing for a new standard in health care

marketplace. Recruited for disease management / care coordination / health

coach consultant roles on behalf of health plans to maximize health

outcomes for patients with proper self-care and primary care while

minimizing unnecessary use of tertiary and emergency care. With telephonic

support managed simultaneously a case load of up to 350 patients.

Provided Telehealth Nursing and Care Coordination to Patients with Wide

Variety of Clinical Needs

. Evaluated patients' nutrition, exercise, and self-care practices to

improve their financial, nutrition, and family circumstances in

relation to their health issues. Provided follow-up calls to continue

coaching and strategizing with patients over longer term.

. Managed patients dealing with the top-5 chronic illnesses (cardiac,

pulmonary, diabetes, depression, and arthritis/chronic pain

management) and other comorbidities. Engaged patients on self-

management.

. Coordinated a case load of adult patient base, typically 65+ years

old, with chronic illnesses and tobacco addiction.

. Accessed device monitoring patient data and medical records according

to HIPAA guidelines to minimize reliance on patient memory and

accuracy.

Built Trust of Patients in Care Coordination Model

. Built rapport with patients, via personalization and individualization

of practice, in <15-20 minutes, helping them to self-determine

positive change with motivational interviewing skills.

. Strategized to review and follow up on each patient to maximize the

success of everyone.

. Established a plan for monitoring and following up with complex

patient case load daily, developing a calendar and timeline that met

patient needs and adhered to corporate demand and quality standards.

. Distinguished among those patients needing a connection from those

needing clinical care; treated all issues equally, sorting apart what

patients needed medically and interpersonally.

Coached Patients Telephonically to Self-Directed Health Care Improvement

. Helped patients develop strategies for self-sustenance, appropriate

use of primary care, and satisfaction in their lives and health

situation.

. Provided options for alternative resources for those with limited

income, developing creative options to help patients acquire proper

food, medication, transportation, and other needs related to their

health care situations. Developed a resource guide of referrals for

across the country.

. Provided rapid interventions when patients' weight or blood sugar

data, transmitted automatically and electronically, triggered

potential change with the patient's medical treatment plan (Alere).

. Initiated Disease Management Program with patients 65+, growing

program to 100 members in <4 months. Focused on patients managing high-

risk heart failure/cardiac illnesses. Coordinated management of

current, chronic, and comorbid health concerns (Hometown Health).

Exceeded All Quality Measures Related to Patient Management and Cost

Containment

. Maintained quality of every call at 98%+ (standard 90%-92%), as

evaluated by quality managers adhering to standards set at federal and

state levels, protocols required by URAC, NCQA, and HEDIS/ACO for

accreditation, and unique company requirements.

. Upheld productivity levels of 80%-90% (standard 70%).

SELECTED CLINICAL EXPERIENCE: ACUTE NURSING CARE AND NURSING MANAGEMENT

. Weekend Administrator/ Liaison / Educator (Washoe Village Care Center,

now-Renown South Meadows Medical Center, Reno, NV): Determined from 5

levels of care appropriate placement for residents. Led teams of

clinical and non-clinical staff administrative leadership over

facility operations.

. Nurse Manager, Trauma and Emergency Services (Trinity Medical Center

West, Rock Island, IL): Managed operations and clinical services,

31,000 patients/year, in a 15-bed Level II Trauma Center, emergency

services, and minor treatment area. Led team of 14 RNs and 16

technicians (radiology, paramedics, administrative personnel, and

more). Designed and executed on fiscal and capital budgets that

supported $4.7M annual revenues and $1.3M expenses.

. Nurse Manager (MedPartners Physician Practice Group, San Bruno, CA):

Managed clinical operations and created systems for 7 multi-site

physician practices. Supervised and coached 6 RNs, 3 LVNs, and 26

medical assistants (including 4 lead RNs and 3 lead LVNs, 2 telephone

advice RNs, and 1 utilization review MA). Effectively recruited and

hired 11 of 35 positions.

. Acute Care Clinical Nurse, 21 years: Provided expert hands-on clinical

care to neonate through geriatric patients in wide variety of hospital

and clinical patient care settings with organizations including

Department of Veterans Affairs Medical Center, Palo Alto, CA; Kaiser

Permanente, Walnut Creek, CA; Columbia/HCA (San Leandro Hospital), San

Leandro, CA; United States Postal Service, San Jose, CA; and Overland

Park Regional Medical Center, Overland Park, KS.

PROFESSIONAL DEVELOPMENT and CERTIFICATIONS

Bachelor of Science, Nursing, Avila University, Kansas City, MO.

Nevada Registered Nurse (RN) License, Current.

California Registered Nurse (RN) License, Current.

Certified, American Heart Association Basic Life Support.

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