Candace Taylor

Identification of health plan members' medical, behavioral, social, and functional needs through the completion of health risk assessments. Develop comprehensive, interdisciplinary plans of care targeting health education, preventative care, and online health tools, which focus on compliance with health management and avoidance of unplanned care in the inpatient and ER settings. Care coordination and collaboration with members' personal support systems, medical providers, and community-based resources to foster optimal health outcomes for members. Adherence to regulated workflows defined by the Centers for Medicare and Medicaid, as they relate to health risk, transitions of care assessments, and individualized care plans.

Service coordinator through the Pennsylvania Housing Finance Agency. Completion of assessments to identify, coordinate, and assist adults and children in a family-based property setting gain access to needed services: medical, social, educational, housing, childcare, and community-based. Advocacy and education as it relate to affordable housing for low-or moderate-earning adults, seniors, and those with special needs.

Completed psychosocial assessments with patients in the hospital setting: acute care, oncology, maternity, behavioral health, and emergency room. Discussions as they relate to medical, behavioral health history, external support systems, cultural, and spiritual factors that may contribute to discharge planning and disposition. Collaboration with the interdisciplinary healthcare teams, patients, families, legal representatives, and appropriate community-based services is essential to ensure that patients are discharged to the appropriate level of care. Daily patient rounding and coordination of family meetings to discuss treatment plans. Referrals and resources, as applicable, to support patients through transitions of care. Adherence to hospital policies and practices as they relate to capacity management and length of stay. Assisted in the implementation of a hospital-based telehealth palliative care program.