Registered Nurse Care
Resume:
Cheryl A. Ortiz
*********@*****.***
Summary: Registered Nurse experienced in leadership, case management and direct care in a broad range of healthcare settings, including acute care, home health care, hospice, LTAC,-skilled, rehab, psych, assisted living and insurance, who possesses the knowledge and skills necessary to effectively apply all aspects of the nursing process within a collaborative, interdisciplinary practice setting.
This broad based clinical knowledge enables to this nurse to effectively implement health promotion and prevention interventions, manage acute and chronic illness states, assist patients in the attainment of optimal levels of functioning through rehabilitation and provide supportive measures for the dying patient and their significant others.
Purpose: To utilize my strengths, education and experience to help facilitate positive patient experience and health outcomes.
To function as a consultative resource to clinicians and departments for assigned programs serving as the subject matter expert.
To collaborate with key stakeholders for the planning, development, implementation, and program evaluation for assigned programs.
To provide leadership/facilitation to assess, plan, implement, supervise/ coordinate, and evaluate assigned programs in full compliance with regulatory guidelines.
To develop and recommend short· and long-range goals for the continued development and maintenance of assigned programs.
To use research-based evidence to formulate, evaluate, and/or revise policies, procedures, protocols, and practices
To synthesize, interpret, and makes decisions based on complex sources of data as they relate to assigned patient population.
To facilitate staff professional practice by role modeling, teaching, and mentoring.
To promote inclusion in order to achieve organizational goals.
Education
Master’s Degree in Preventative/Admin Medicine Bachelor’s Degree in Nursing
University of Wisconsin-Madison University of Dubuque
Madison, WI Dubuque, IA
Graduated December 1997 Graduated December 1992
Career Experience
Mar 3rd, 2019-Present SSM Dean Health Plan, Madison, WI
Registered Nurse Case Manager
Responsibilities:
•Case and Disease Management support and care navigation of voluntary complex care patient's through telephonic service and face to face contact in the acute care setting.
•Improving patient health thru education on disease self management.
•Utilizes motivational interviewing and provision of emotional and spiritual support. Uses the nursing process to identify needs and create a patient centered nursing plan of care, determine referral needs to professionals and/ or services, while promoting quality care and effective treatment within the company’s policies and procedures.
•Assist members diagnosed with catastrophic illness, a trauma-related event, unstable acute and chronic diseases, multiple poorly self-managed medical conditions, frequent ER use, newly admitted and/or discharged acute care patients. Assist in transition of care to ensure understanding of Pt discharge instructions and medication orders/compliance.
Job duties:
•Completing assessment of patients from various referral sites and determining if they qualify for case management. If so, development of a plan of care in conjunction with the member, as to what health goals they would like to work on. .
•Development of relationships and fostering communication with member, family, primary care physician and specialty providers, as well as community members.
•Assist members with care navigation, including proper utilization of in-network and out-of-network providers, within their insurance plan provisions.
•Provide education, behavior change and motivation according to the member’s desired mode and goals.
•One-on-one phone or in-person education and support provided by nurse case manager in partnership with social workers, pharmacist and trained support staff.
•Offer suggestions and participate in Quality and Process Improvement teams.
•Work closely with inpatient direct care staff and case managers to ensure patient has a good discharge plan in place.
•Care coordination within the health care system and during transition of care time frames.
•Promotion of evidenced-based treatment plans and safe medical practice, based on patients individual needs.
•Individualized approach to support patients self-care needs from a whole person approach.
Sep 11, 2017-Dec 17th, 2018 Agrace Hospice Inc. Madison, WI
Registered Nurse Case Manager
Responsibilities:
•Through a collaborative interdisciplinary approach, provides coordination of direct and indirect care, ensuring a patient and family centered focus.
•Maintained accountability for nursing practice and patient outcomes in order to enhance quality of life for patients, families and significant others facing serious illness.
•Provided care of patient needs in all ages and life stages; their values and previous life experiences and well as assessing their overall physical and mental health and related co-morbidities.
•Served as the subject matter expert and consultant on nursing care of the hospice patient.
•Coordinated care with their primary care provider, specialists, and hospice providers for treatment of hospice-related and non-related sub-acute and chronic health problems to enhance patient comfort.
•Collaborated with the interdisciplinary team to provide referrals to community resources and discharge planning when appropriate.
Job duties:
•Provision of direct and indirect care utilizing nursing process to create a care plan and monitor outcomes.
•Patient and family/significant other education.
•Provided multi-faceted disease/case management triage.
•Assisted patient and family in recognizing and working through end-of life issues.
•Overall focus on psychological, physical, and spiritual patient comfort and satisfaction.
•Medication set up, reconciliation and evaluation of effectiveness,
•Blood glucose and vital sign monitoring and analysis, oxygen administration/ monitoring saturation levels;
•IV infusion, PICC line care, phlebotomy, ostomy and catheter care, wound and skin care.
Dec 14, 2014-June 6, 2017 Bethel Home and Services, Viroqua, WI
Administrator 4/1/2016-6/6/2017
Responsibilities:
•Responsible for the overall leadership and management of 85 bed facility, including meeting established goals and outcomes, ensuring regulatory and organizational compliance, directing and coordinating work, financial and operational stability, risk management, customer satisfaction and demonstrating spiritual leadership.
•Oversaw employment of over 150 employees lead by 5 department managers, including Social Service; Activities; Nutrition Services, Medical Records, and Nursing Services.
•Worked with Care Management teams to ensure smooth transitions throughout the continuum of care.
•Provided direct care to residents.
•Assisted Social Work/Nursing Admission Team in telephone screening for appropriate referrals from, and maintaining positive relations with, multiple internal and external sources.
•Provided leadership/facilitation to assess, plan, implement, supervise/ coordinate, and evaluate assigned programs in full compliance with regulatory guidelines.
•Coordinated telephonic intake of referrals and admissions, determined medical necessity and worked with insurance companies for approval.
•Facilitated coordination of care, from prior to admission through discharge, to multiple levels of care and services as appropriate.
• Ensured satisfaction with contractors, (including VA), providers and vendors.
•Collaborated with key stakeholders for planning, development, implementation, and program evaluation
•Served as a consultative resource to clinicians and departments for assigned programs serving as the subject matter expert for care of the geriatric patient and compliance of regulatory bodies.
•Facilitated coordination of care, from prior to admission through discharge, to multiple levels of care and services as appropriate.
•Developed and recommended short· and long-range goals for the continued development and maintenance of assigned programs.
•Used research-based evidence to formulate, evaluate, and/or revise policies, procedures, protocols, and practices
•Synthesized, interpreted, and made decisions based on complex sources of data as they relate to assigned patient population.
•Facilitated staff professional practice by role modeling, teaching, and mentoring.
•Promoted inclusion in order to achieve organizational goals.
Accomplishments:
•Consolidated facility space utilization from 6 wings to 4 wings to decrease costs and improve quality of care.
•Increased facility census through expanding service line to patients with psychiatric /behavioral concerns.
•Successfully won Immediate Jeopardy case with State BQA related to a Pneumonia immunization citation.
•Created procedural infrastructure to bring facility into regulatory compliance with revised Mega rule requirements for long term care related to abuse and neglect and residents rights.
•Focused on efficiencies related to information systems by installation of updates in EHR and scan manager in Central Supply.
•Expanded communication touch points for patients and families to improve case communication and customer satisfaction.
•Created communication systems utilizing the EHR to manage pt referrals, insurance verification, nursing assessment, acceptance/denial, communication with discharge planner/referral source thru admission to decrease time gaps, improve referral source and internal/external customer satisfaction and improve census.
•Obtained a contract with a local mental health provider to assess and recommend treatment to patients in need of more complex treatment regimens related to their psychiatric diagnoses.
Director of Nursing Services 12/14/2014-3/31/2016
Responsibilities:
Provided leadership/facilitation and clinical oversight of the provision of quality care, including, but not limited to:
•Assessing, planning, implementing, supervising/coordinating, and evaluating
assigned programs in full compliance with regulatory guidelines.
•Staffing, including recruitment and retention;
•Scheduling and ensuring proper use of resources within budget parameters,
•Development of new and revised policies and procedures as well as clinical guidelines,
•Monitoring of resident’s health conditions, both physical and mental, to prevent declines,
•Provision of education and coaching to nursing staff,
•Direct supervision of ADON, Staff Development Coordinator, MDS/Restorative Nurse and Scheduler.
•Interacting with other departments for the improvement of customer satisfaction and quality of care.
•Collaboration with key stakeholders for the planning, development, implementation, and program evaluation for assigned programs
•Screened referrals for appropriateness via telephone and chart review.
•Served as a consultative resource to clinicians and departments for assigned programs serving as the subject matter expert for care of the geriatric patient and compliance of regulatory bodies.
•Facilitated coordination of care, from prior to admission through discharge, to multiple levels of care and services as appropriate.
•Developed and recommended short· and long-range goals for the continued development and maintenance of assigned programs.
•Used research-based evidence to formulate, evaluate, and/or revise policies, procedures, protocols, and practices
•Synthesized, interpreted, and made decisions based on complex sources of data as they relate to assigned patient population.
•Facilitated staff professional practice by role modeling, teaching, and mentoring.
Promoted inclusion in order to achieve organizational goals.
Accomplishments:
Created a substantial increase in CMI thru Restorative Nursing Program that doubled in number of residents served.
•Formed Pain, Behavior and Fall Team to improve Quality Measures.
•Decreased re-hospitalization rates of residents with heart failure from > 25% to < 15%.
•Created “Transitions of Care” team to improve internal transition across the CCRC.
April 6, 2009- Dec 2, 2014 Home Health United, Madison, WI
Director of Home Care and Central Intake/Scheduling
Responsibilities:
•Oversee operations of six home care branch offices serving 25 counties in South Central Wisconsin, Central Intake, which included:
•SSM hospital liaison’s for processing all referrals,
•Centralized Scheduling,
•Central Intake,
•Telehealth,
•Wound Care and Infusion Programs, and
•Palliative care
•Directly supervise 9 managers of these programs which oversaw 300 employees.
•Responsible for a 25 million dollar annual revenue base with an ADC of over 1000 patients.
•Provided leadership/facilitation to assess, plan, implement, supervise/ coordinate, and evaluate assigned programs in full compliance with regulatory guidelines.
•Collaborated with key stakeholders for the planning, development, implementation, and program evaluation for assigned program,
•Functioned as a consultative resource to clinicians and departments for assigned programs serving as the subject matter expert.
•Provided leadership/facilitation to assess, plan, implement, supervise/ coordinate, and evaluate assigned programs in full compliance with regulatory guidelines.
•Facilitated coordination of care, from prior to admission through discharge, to multiple levels of care and services as appropriate.
Accomplishments:
•Implemented Chronic Disease Management certification initiative and developed Palliative Care program;
•Initiated agency wide Centralized Scheduling with focus on continuity and coordination of care;
•Developed a data driven clinical staffing model;
•Standardized treatment protocols for Heart Failure, Pneumonia, COPD and CVA;
•Increased case mix across all branches to agency high of 1.47 from less than 1.0;
•Achieved Home Care Elite status in 2009-2013; Worked collaboratively with Dean and Dean/St Mary’s Ventures in addition to sponsoring hospitals to improve referral systems, decrease re-hospitalizations, improve transitioning of care and decrease physician paperwork;
•Increased availability of data to support management decision making; Increased involvement of PCMs and SW in development of relationships with referral sources; developed referral source tracking processes;
•Created and implemented RN/LPN Preceptorship Program;
•Created Infusion, Wound Care and Lymphedema Specialty programs for implementation of Best Practices;
•Clarified Clinical Expectations for Time and Travel;
•Created and Implemented a Clinical Management Orientation Program;
•Researched options for increasing use of in-home Teleheath, beyond present Home monitoring systems.
Lead Patient Care Manager
Accomplishments:
•Creation of Agency wide Staffing Model resulting in decreased overtime and improved staff productivity;
•Developed Library text goals with language from the OASIS to further improve outcomes and efficiency;
•Created various flow charts for staff to use as references for complex systems;
•Improved partnership with sponsoring hospitals thru representing HHU on St Mary’s Madison Congestive Heart Failure Team, St Clare Baraboo Re-admissions and Palliative Care Teams, and St Mary’s Janesville Palliative Care Team.
Patient Care Manager, Sauk Prairie Branch
Responsibilities:
•Directly supervised RNs, LPNs, CNAs, Physical and Occupational Therapists and Social Work for branch.
•Served an Average Daily Census of 125 Home Care patients in a geographic area covering 4 counties.
•Responsible for financial and quality measurement performance.
Accomplishments:
•Maintained the highest branch case mix amongst the six HHU locations.
• Implemented a case conference model that focused on accuracy in oasis scoring which improved outcomes and financials.
Sep 2006-April 3, 2009 Attic Angel Place, Middleton, WI
Director of Nursing
Responsibilities:
•DON for a 44 bed SNF, 20 bed CBRF Memory Care Unit, 36 unit Residential Care Apartment Complex Assisted Living, and 72 RCAC Independent Living Apartments with nursing services.
•Responsible for oversight of physical, emotional, psychological and spiritual needs of residents within the CCRC in order to ensure that quality services are delivered with respect for resident choice and autonomy.
•Ensured compliance with RCAC, CBRF, SNF and CMS regulations as well as CCRC and other accepted Standards of Practice.
Accomplishments:
•DON for a 44 bed SNF, 20 bed CBRF Memory Care Unit, 36 unit Residential Care Apartment Complex Assisted Living, and 72 RCAC Independent Living Apartments with nursing services.
•Achieved CMS Five Star rating based on Quality indicators, survey history and staffing levels.
•Decreased Quality Indicator flags from 4-6 to 0-2/month by improving accuracy of MDS coding, interdisciplinary review and action, and direct care processes.
•Gained an improvement in overall customer and employee satisfaction ratings, including scores in relation to responsiveness and care and concern of management.
•Created policies and procedures to address nursing and interdisciplinary issues across the continuum of care with a strong focus on aging in place, including an emphasis on fall and pressure ulcer prevention and pain management.
•Actively involved in development of managers in budget, staff and resident care management.
•Developed start up policies and procedures, management staffing structure and hiring as well as programming for Alzheimer’s and other dementia facility.
•Improved nursing education program and quality of educational offerings to improve nursing practices related to disease management.
July 2005- July 2006 Wisconsin Dells Health and Rehab Center, Wisconsin Dells, WI
Director of Nursing
Responsibilities:
•DON for a 90 bed skilled nursing and rehab for profit facility.
Accomplishments:
•Involved in development of an Alzheimer’s and other Dementia unit.
•Led facility turn around projects for facility regulatory compliance and within budgetary requirements.
•Implemented consistent assignments for continuity of care and patient and family satisfaction.
Nov 1985-June 2005: Upland Hills Health: Nursing and Rehab Center, Dodgeville, WI
Nursing Home Administrator
Responsibilities:
•NHA for a 44 bed Medicare, Medicaid and JCAHO certified hospital based long term care and rehab facility.
•Member of Administrative Team, addressing and coordinating issues across the continuum of care, including acute, home health and hospice, outpatient physician specialty clinic, sub-acute and long term care.
•Managed a 2.5 million dollar annual budget that included 100 employees from multiple departments on 3 shifts.
•Negotiated and managed multiple contracts for insurance and care provision
Accomplishments:
•Creation of organizational Strategic, Operational and Budget process and procedures.
•Oversaw design and construction of an Innovative Design Award winning “household/community” concept multi-million dollar skilled nursing facility. Involved from ground up in pro-forma development and financial, architect and contractor selection, value engineering and project management.
•Creation of community based programs including emergency telephone response, person in-home care giver, adult day and respite care.
•Dramatically decreased licensed nursing turnover through creation of a Shared Decision Making nursing model.
•Became certified as a Wisconsin Forward Award Examiner.
•Achieved consistent CHSRA quality indicator overall scores of 18-25% better than the average Wisconsin facility through working with staff to improve and standardize processes.
•Resident care deficiency-free Bureau of Quality Assurance surveys 5 years running.
•Improved Accounts Receivables Past Due greater than 120 days by 120% within 6 months.
Certifications
2013-Chronic Disease Management-Sutter/Penta
2016-Credential of Ministry/Christian Harvest Church
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