SUSAN WAGNER-SALANTI, RN, BSN, PHN, B-C

**** ********* ***

Redding, CA 96001

530-***-****

PROFESSIONAL EXPERIENCE:

U.S. DEPARTMENT OF VERTERAN AFFAIRS, Redding, CA

Intensive Community Mental Health Recovery Services (ICMHRS)-RANGE RN October 2020 – February 2022

Primarily responsible for the management, integration, evaluation of the ICMHRS-RANGE program

Provide nursing case management services to 30 Veterans per week with SMI, severe functional impairment, and high inpatient mental health unit utilization

Responsible for coordination of care with community and VA services through the continuum of care, patient education, and supporting factors that impact customer service

Actively participate on an interdisciplinary team where all members of the team are available to provide clinical services for the Veteran

Coordinate and conduct regular monthly, quarterly, annual and as needed, in-home and telephonic clinical assessments and provide interventions in a community setting

Provide high quality documentation and revision of care plan of Veteran’s response to interventions in the medical record using approved facility or National templates available, or using best practices to write notes when templates were not available

Regularly conducted 30+ chart reviews per week in order to provide the highest levels of program coordination and case management for the Veterans

Regularly provide recommendations to co-workers and executive leadership in processes, priorities, and programmatic objectives

Conduct formal and informal presentations to justify and defend programmatic aspects of mission critical programs

U.S. DEPARTMENT OF VETERANS AFFAIRS, Redding, CA

CAREGIVER SUPPORT PROGRAM RN February 2016 – November 2020

Responsible for timely completion of the initial, quarterly, and annual in-home assessments (i.e., in-home visits, Telehealth VA Video Connect, V-Tel, or Telephonic) for patients enrolled in the Caregiver Support Program

Participated and served on the strategic planning committee, The Tiger Team, to develop the CSP program orientation and domestic violence standard operating procedures

Provide clinical, evidence-based services/interventions and education for the caregiver and veteran

Educate staff on caregiver issues, develop resources and monitor continuous quality improvement activities

Provide outreach by developing effective partnerships with local, state, federal agencies as well as non-governmental organizations

Provide immediate crisis intervention during in home assessments if Veteran is experiencing mania, suicidal ideation/ homicidal ideation, active PTSD symptoms, personality disorders and medical psych diagnosis within this Veteran population

Use screening tools such as Columbia- Suicide Severity Rating Scale (C-SSRS) and Depression Screening (PHQ-9) to ensure coordination of necessary care

Administratively responsible for the clinical programming and daily operations, as assigned and the management of data related to the program at the facility level

Possess advanced knowledge of the services and benefits available for caregivers from VA, as well as other federal, state, and private sector entities

Responsible for monitoring the well-being of eligible Veterans receiving personal care services and sign patient care responsibilities based on their needs and competencies of staff

Responsible for quarterly monitoring which includes home visits and other methods of monitoring as determined appropriate such as video on demand, tele-health or clinic appointments for caregiver/veterans who require a review of skills and abilities of the Caregiver and well-being of the Veteran

Complete in-home initial assessments as determined appropriate for referral of General Caregivers identified by the PACT or the Caregiver Support Line

Clinically responsible for the assessment of the Veteran's in-home care needs; assessment on the non-licensed caregiver to determine if adequate care is rendered to meet the veteran's care needs and to fulfill the qualifications for the Program of Comprehensive Assistance Family Caregiver guidelines; Assess the home for safety, identifying any needed structural modifications or additional equipment to successfully care for veteran in the home setting

Participate in research or facilitate special projects designed to validate and improve healthcare delivery related to caregiver support

U.S. DEPARTMENT OF VETERANS AFFAIRS, Northern California

COMMUNITY HEALTH/COMMUNITY NURSING HOME RN February 2016 – November 2020

Provide clinical nursing services to Veterans in VA skilled and non-institutional programs including: Homemaker/Home Health Aide (H/HHA), Adult Day Health Care (ADHC), In-Home-Respite, Medical Foster Home and Contract Nursing Home (CNH)

Serve as a VA liaison between community nursing care providers with the Redding/Chico CBOC, Sacramento VA Hospital and the East Bay Martinez VA, assuring that standards of patient care are being met

Responsible for performing annual CNH inspections, pre-inspections for potential VA contracts, and follow up visits within rural and highly rural geographic areas

Organize, document and submit assignments in a timely manner

Serve as a subject matter expert for CNH, CADHC, H/HHA, MFH and Respite programs, which includes developing and overseeing the program evaluation material and objectives, providing consultation, and reporting qualitative data as needed

Perform analysis and technical data management during budgetary process in order to keep the HHA/CNH and in-home respite programs within fiscal year budgetary allowances

Regularly track, analyze and present program statistics, such as: visits, referrals, demographics, program equipment and utilization, and Veteran satisfaction

Collaborate with VA Office of Organizational Improvement to standardize and develop effective methods of communication among VA staff via implementation of Huddleboards, and to increase utilization of VA/community resources with Veterans via standardized template letters

Drafted, submitted and received recognition for Office of Rural Health NCHCS proposal to expand the HBPC program to cover the entire Siskiyou County, which was ultimately approved by VA National and implemented beginning FY17

Provided crisis intervention and task centered/problem- solving to over 200 displaced Veterans by California's deadliest fire in history, the Camp Fire

U.S. DEPARTMENT OF VERTERANS AFFAIRS, Sacramento, CA

Home Telehealth Nurse Care Coordinator, RN CN II Step 5 December 2008 – September 2013

Developed, managed and implemented the Home Telehealth program for Northern California for rural and highly rural Veteran patients

Provided professional assessment, coordination and planning of multiple health care services, using health informatics, disease management and Home Telehealth technologies

Ensured initial and ongoing assessments of patients identified their needs, issues, care goals and appropriate resources were provided for care management

Maintained communication with the Veteran’s Patient Aligned Care Team (PACT) in order to provide appropriate care coordination.

Provided community outreach events and meetings for rural and highly rural VA patient populations living up to 300 miles away from Sacramento, CA

Saved $9M the first fiscal year of Telehealth program by decreasing 911 calls and unnecessary hospitalization

Researched, analyzed and presented data in support of implementing Evidenced Based Practices, such as daily monitoring of patients decreasing HTN, HGA1C levels, decreasing re-admissions for the cardiac patients

Coordinated and educated system-wide RN case managers on the benefits of the Home Telehealth program which significantly increased program census

Served as a member of the Clinical Outcomes team, which assisted in developing algorithms for standing medication

Maintained knowledge and contacts of community service programs within the Northern California region

Received the 2010 Achievement Award for VA Northern California Healthcare System Veterans for Home Telehealth program efforts

U.S. DEPARTMENT OF VETERANS AFFAIRS, Sacramento, CA

Psychiatric Intensive Care Unit (PICU) December 2008 – April 2009

Temporarily provided Inpatient Mental Health nursing services to medically complex post-surgery and medical patients with a variety of modalities

Managed patient care in an astute manner, which promoted positive patient outcomes utilizing mental health nursing assessments

Facilitated and led group therapy, interacted with IDC team within the VA system and county wide systems

Conducted and documented comprehensive holistic health assessments

Participated on multidisciplinary treatment planning teams to ensure the highest level of care

NORTHERN CALIFORNIA REHABILITATION HOSPITAL, Redding, CA

Medical Surgical Clinical Nurse April 2008 – December 2008

Provided direct patient care to critical patients in a long-term acute hospital

Extensive experience with assessments, IV infusions, wound care of the MRSA patients, ventilator patient care and administered medications per established policies

Successfully communicated patient needs with MD

Participated on an interdisciplinary team with PT, OT, ST, RT, and ventilator assist

Maintained knowledge of nursing, medical practices and procedures, as well as state and federal regulations specific to operation and licensure

Provided assessment, treatment, and planning for a complex patient with decision-making surrounding life and future concerns

MEDICAL HOME CARE PROFESSIONALS, Redding, CA

Home Health Clinical Nurse June 2007 – April 2008

Provided nursing services and case management to medically complex patients to ensure continuity of patient care

Communicated and closely interacted with community physicians and services in order to coordinate the use of increased psychiatric nursing skills, home infusion therapy, wound care management and wound vac equipment, care of the cardiac patient, pediatric nursing care, and clinical teaching of disease processes and skilled intervention of the home bound patient setting

Demonstrated excellent communication and documentation skills using electronic medical record computerized charting (OASIS), along with critical thinking ability

Conducted regular assessments and nursing diagnostics

Employed as a per diem staff nurse for emergency patient complications and staffing issues

ACCENT CARE HOME HEALTH AGENCY, Redding

Nurse Clinical Supervisor January 2004 – June 2007

Provided Clinical Supervision of patient care consistent with scientific principles, agency policy and procedures, as well as the maintenance of quality of patient care under Federal, State, and local regulation and accreditation standards

Supervised 30+ licensed personnel of RN’s, LVN’s, PT, OT, ST, MSW, CHHA‘

Utilize the agency’s clinical software to plan, coordinate the delivery of patient care

Complied with applicable legal requirements, standards, policies and procedures

Assist clinical staff with troubleshooting patient situations, conducted hiring and terminating, and disciplined employees as needed

Administratively responsible for developing the staffing monthly schedule, IDC meetings for quality of patient care and networking with community services

Performed chart auditing to ensure the highest level of care

Maintained relationships with community services and reported necessary cases to APS, CPS, Golden Umbrella, senior services, and hospital case managers

Responsible for obtaining the agency’s State and Federal licensures

Volunteered myself to provide on-call status to nursing staff if they encountered a patient centered care problem

CALIFORNIA FORENSIC MEDICAL GROUP/PRISON HEALTH SERVICES, Northern California

Charge Nurse April 2004 – June 2007

Provided Correctional/Forensic nursing with a wide range of clinical challenges

Conducted patient assessments in the sally-port prior to booking and assess patient for medical competency and ensure ETOH, and Opiate withdrawal protocol was implemented as necessary

Participated on an interdisciplinary team of psychiatrists, RN’s, NP’s and correctional staff to ensure safe discharges

Assisted on psychiatric evaluations and assisted with the psychiatric telemedicine clinics at the facility

Educated correctional staff on deescalating challenging behavior and on safety in a crises/hostage situations

Educated other RN staff members on designating appropriate time for difficult patients and listen to their needs, which decreased anxiety and manipulation tactics from the inmate

Promoted mutual respect and trust for patients and staff while maintaining security and continue cognizant of potential hazards

Ensured prescribed medication was administered as ordered using the formulary

Coordinated chronic disease, assessed for suicidal ideation patient and prevention, IV infusion, and diabetic management

Functioned as the Charge Nurse on the evening shift and implemented an inmate sick call clinic independently

Responded to numerous volatile encounters and outbreaks and earned respect from provider and co-workers for remaining calm and quick thinking to restore the safety and security of the patient and staff

September 1997- April 2004: I was disabled from a serious auto accident and rehabilitated during this period

BARTON MEMORIAL HOSPITAL HOME HEALTH/HOSPICE AGENCY, South Lake Tahoe, CA

Clinical Nurse May 1995 - September 1995

Provided skilled in-home nursing services in a rural setting

Regularly performed home IV infusion, CABG’s, Pediatrics, Cancer/chemo patient’s, wound care, Diabetic teaching and patient care

Planned, organized and developed a successful hospice division for agency

Nominated for training at UC Davis Medical Center on Hospice care

Responsible for obtaining licensure and credentialing for Medicare and State regulations

Educated and provided support to families and patients during critical decision-making periods pertaining to Goals of Care, Life sustaining treatment decisions, End of Life care, and any other concerns pertaining to their overall healthcare plan

Obtained specialized training on nursing practices for home bound patients, as well as, training on Nursing practices for home infusion therapy using the CADD pump, and wound care for the post-operative patient.

Demonstrated leadership and autonomy in an uncontrolled setting and successfully prioritizes and manages the patient if undue circumstances were encountered such as power outages, medication allergies, and combative family members

PROFESSIONAL EXPERIENCE- PERIOPERATIVE SERVICES:

1993-1997 RN/OR Manager – SLT Plastic and Reconstructive Surgery Center.

1990-1997 RN/Manager - Barton Memorial Hospital, Department of Surgical Services

1988-1991 RN - Sutter Roseville Hospital Cardio-Thoracic Department and Sutter Memorial Hospital CVOR

1987-1989 RN Instructor - Sacramento Board of Education/Instructor Surgical Technology

1987-1988 RN Instructor - Academic Consultant/Independent Contractor

1985-1988 RN - UC San Diego Medical Center/UC Davis Medical Center, Sacramento

1984-1985 RN - UC Davis Medical Center

1981-1984 RN - Kaiser Permanente Hospital

EDUCATION:

1970-1973 American River College, Sacramento, Ca

1975-1976 Valdosta Voc Ed College, Valdosta, Ga. Licensed Practical Nurse

1977-1981 Abraham Baldwin Agriculture College, Tifton, GA Registered Nurse, AND

1995-1997 University of St Francis, Joliet IL. Bachelors Health Arts Science

2003 American Institute of Holistic Theology, Candidate for PhD Alternative Medicine

2011 ANCC Gerontological Nursing Certification renewal 2020

2014 Simpson University RN-BSN, Public Health Nurse Certificate

AWARDS AND CERTIFICATES:

Special Contribution Award (Department of Veterans Affairs) May 2010

Certificate of Achievement “Excellence Defined: Advancing Rural Health through Best Practices” Winter Conference 2011

North Valley Stand Down Association certificate 2011

Healthcare Talent Management VHA Mentor Certification Program

Certification mentor Fellow level through Veterans Health Administration

National Mentor Certification Program 2012

Home Telehealth Certificate Program 2012

2012 Veteran and Family Health Education RDG OPC Education Committee Poster Presentation

Certification for ELNEC Hospice/Palliative Care Nursing 2012

Certificate of Completion for Home Telehealth Annual Competency 2012

Certificate of Appreciation of Home Telehealth and the PACT Team

Developed Program Brochure used for No Calif Healthcare System Department of Veterans Affairs

Alpha Sigma Lambda Honor Society member (current)

Simpson University Nursing Honor Society

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