Caitlin Marie Palmer

* ******** ****, *** *, Stafford Springs, Ct 06076

Email: caitlinpalmer24@gmail

Cell: 860-***-****

EMPLOYER

Nurse Navigator-Digestive Health Center-Hartford Healthcare

-July 2019-September 2021

Program Lead/Nurse Navigator/Care Coordinator

-Orthopedic Associates of Hartford/Hartford Hospital Bone and Joint Institute P.C. July 2015-August 2017

-Bundled Payment Care Initiative/Transitional Care Coordinator

Manager of Care Management-Coordinated Regional Care-Prospect Medical/ACO

-August 2018-July 2019

-

Nurse Navigator/Total Joint Program Coordinator –

-Holyoke Medical Center-Holyoke, MA

-HMC Orthopedic Surgeons-September 2014-April 2015

Community Health Nurse Navigator/Care Coordinator-August 2017-August 2018

-St Francis Healthcare Partners- Population Health Management

Hartford Hospital-Orthopedics/Med/Surg-September 2010-February 2017

-Registered Nurse/Charge Nurse/Per Diem

-* Nurse Preceptor/ Resource/ Charge RN/ Geriatric Resource RN/ Infection Control Representative

LICENSE/CERTIFICATIONS

Registered Nurse- State of Connecticut Department of Public Health

HONORS/AWARDS

Linda Richards/June Long Award Recipient-May 2012

oRecognition for Clinical Excellence and Dedication to Caring

EDUCATION

New York University

Bachelor of Science - NURSING- January 2009-May 2010

University of Connecticut Fall 2006

Bachelor of Arts - Sociology

Specific Attention to Health and Family Studies

Caitlin Marie Palmer

1 Schwanda Road, Apt 4, Stafford Springs, CT 06076

Email: caitlinpalmer24@gmail

Cell: 860-***-****

RELEVANT EXPERIENCE/LEADERSHIP ACTIVITIES

Nurse Navigator-Digestive Health Center/Hartford Healthcare

Develop Nurse Navigator Tracking Template-EPIC

Collaborate with HHCMG Surgical/Colorectal Providers/Nurses to build patient education materials/develop comprehensive plan of care

Track Conifer Digestive Health Patients-Assist patients with access to HHC

Facilitate patient access to ancillary services within the HHC system

Track Pancreatic Cyst patients through preoperative workup and access to care/procedures

Orthopedic Associates of Hartford P.C./Hartford Healthcare-Bone and Joint Institute Nurse Navigator/Care Coordinator Program Lead

Facilitate and Implement the Bundled Payment Care Initiative at Orthopedic Associates of Hartford P.C. for DRG 469/470/483 (Total Joint Orthopedic Patients)

Lead pilot programs with associating healthcare entities regarding safe home transitions with home care agencies, Telehealth, Utilization Review, Risk assessment and stratification of medical-surgical patients. Facilitate transitions of care/Track patients across the continuum

Collaborate with the PREPARE Pre-operative risk assessment comprehensive program (HHC Bone and Joint Institute) to ensure efficient transitions for discharge/educate patients/collect preoperative risk assessment data to develop an individualized plan of care for the patient/family. Ensure patients have an optimal seamless experience

Serve as IT Liaison to assist in development of platforms (EPIC) to identify high risk patients/Analyze quality metrics and case coordination tracking of patients

Responsible for serving as a liaison for providers, post-acute care teams, and identify opportunities to build new clinical initiatives

Perform Case Management and Preadmission Assessment screenings, in coordination with the inpatient teams at Hartford Healthcare, St Francis Medical Center and The Hospital of Central Connecticut

Collaborate with Case managers and Inpatient Interdisciplinary team to facilitate safe transitions for patients/facilitate home services/DME/Social Services-Completion of PASRR Screening, ALLSCRIPTS Referrals

Educating Peers on Transitional Care Pathways with Preferred Provider Networks

Manage Medicare patients through a 90-day episode of care-Focusing on transitions in care, optimal quality performance measures. Educate and engage patients throughout the pre/post op process. Provides information and guidance to patients to improve self-management skills/knowledge of both chronic disease processes, community resources and post-surgical recovery.

Caitlin Marie Palmer

1 Schwanda Rd, Apt 4, Stafford Springs, CT 06076

Email: caitlinpalmer24@gmail

Cell: 860-***-****

Monitor Quality Improvement Data and Quality Metric Analysis

Accountable for initiating post-operative patient care plans, conducting telephonic preoperative risk assessments, identifying barriers to care and transitional needs

Develop plans of care for Orthopedic patients/families. Coordinate with PREPARE Risk Assessment Center to optimize patients prior to surgery.

Effectively develop and implement communication pathways for continued correspondence regarding patient’s transitions throughout their episodes of care. Communicate plans of care and collaborate with healthcare providers (PCP, Specialists) and personnel across the continuum

Coordinated Regional Care-Prospect Medical

Oversee and develop care management processes/programs/operations for ACO/VBR/PCMH+ Contract negotiations. Emphasis on Quality metrics/CMS measures

Ensure holistic collaboration amongst participating entities (Inpatient CM, Post-Acute, Advance Life Care, Home Care, PCP, Specialists)

Provide holistic patient care within transitional care management, behavioral health and social determinants of health

Facilitate Transitional Care Management Workflow Progress and Programs

Oversee Quality Metrics/Measures for Contracted Insurance Plan/ACO/Focus on Utilization Review for accountable entities

Coordinate with physicians/providers/leadership to ensure workflow process outcomes

Analyze Key Performance Metric Outcomes/Indicators-(Retention, Readmission, Admissions/1000, SNF LOS)

Holyoke Medical Center-Nurse Navigator/Total Joint Coordinator

Coordinate care across the continuum for Total Joint Patients at HMC Orthopedic Surgeons and Holyoke Medical Center

Closely monitor through statistical analysis -Performance Measures - Infection Rate/Readmit rates in order to decrease overall occurrence within Orthopedic population at Holyoke Medical Center-Based upon Joint Commission Disease Specific Program

Correlated Discharge Process with Case Coordination/Planning for post-surgical Joint Replacement Patients/Ensure appropriate LOS/LOC

Caitlin Marie Palmer

140 West Main St, Apt 3, Stafford Springs, CT 06076

Email: caitlinpalmer24@gmail

Cell: 860-***-****

Saint Francis Healthcare Partners-Community Health Nurse Navigator/Population Health

Identify high risk patients aligned with the ACO via risk assessment platform –Hospital to Home High Risk-Establish Relationships with patients and promote increased self-management

Familiar with ACO, MSSP Regulatory Programs and Utilize Medicare TCM platform

Coordinate with PCP and interdisciplinary team to identify barriers to care and opportunities for additional resources for patients and families

Collaborate with interdisciplinary population health team to identify ongoing health coach/ Social Worker/Chronic Disease/Disease Specific programs

3 Day SNF Utilization Waiver Coordinator under MSSP track 1+ Population Health Platform

Co-facilitate Community Outreach Committee-Live Well events/Pop Health Events for Attributed Patients and Physicians

TECHNICAL SKILLS

Proficient with EMR Applications-EPIC, SCM/Sunrise, Eclinical and MEDITECH, ALLSCRIPTS Case Management Platform-Familiar with Referral Process, PASRR Completion, COMPASS Modules

Complex Case Management Experience

Orthopedic-LOS, UM, LOC, Transitional Care

Understanding of NCQA guidelines

Understanding of HEDIS/MIPS Quality Measures

Data Analysis-Quality Improvement Metrics

Risk Stratification –i.e. LACE Score, AWV, Chronic Disease, Total Cost of Care, UM

Working Clinical Knowledge of Chronic Disease Processes and medications-COPD, ASTHMA, CHF, DIABETES, BEHAVIORAL HEALTH, PAIN MANAGEMENT

Analyze CMS DRG data pertaining to beneficiary claims information, utilization review management

- References Available Upon Request

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