Melanie Hampton LSW

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes. Take patient/family/caregiver level of health literacy into consideration. Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care. Balances resources with patient preferences and goals of care. Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition.
• Complete detailed assessment on every patient in order to establish understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine likeliness of requiring post-hospital services and the availability of such services. Continually reassess discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan.
• Facilitated development and execution of safe, efficient discharges by coordinating with interdisciplinary teams and integrating patient goals, health care assessments, and available resources to ensure successful transition plans and timely post-hospital care arrangements.
• Communicated effectively with patients, caregivers, and interdisciplinary care team to develop individualized discharge plans, serving as liaison to ensure integration of recommendations, test results, and outstanding orders while monitoring progress toward discharge milestones.
• Facilitated collaboration between hospitals and post-hospital care providers to support coordinated patient treatment.
• Recognize and demonstrate shared accountability in development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes.
• Align practice with the mission, vision, and values of the organization. Adheres to ethical standards and codes of conduct of applicable professional organization and UPMC. Maintain clinical knowledge of and ensures compliance with regulatory requirements.
• Advocated for access to services and protection of patient health, well-being, safety, and rights, ensuring that patient/family/caregiver needs were met throughout the discharge planning process.
• Manage cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
• Embrace and incorporate innovation and technology to improve collaboration and patient outcomes. Document care in patient medical chart.
• Provide staff orientation and mentoring as appropriate.

Interviewed patient's social support system to initiate
psychosocial evaluation.

Assisted patients' social
support system in coping with stress related to
hospitalization, disability, chronic/terminal illness.
•Served as resource to hospital staff and physicians
regarding emotional, social, and psychosocial
components of patient's illness and its effects on
their social support system. Assists and facilitates
multidisciplinary team in understanding and
integrating these aspects into plan of care.
•Intervened in crisis situations, appropriately and
effectively applying crisis intervention theory and
skills.
•Worked with Clinical Care Management team to
assess and evaluate patient's social support system
for appropriate level of care or environment setting
to meet care needs across continuum.
•Participated in multidisciplinary care planning
meetings.
•Identified and records clinical, psychosocial, and
financial barriers to smooth transition across
healthcare continuum and assists in identifying and
facilitating system improvements.

Worked with clinical team to provide information
and education to patients and their social support
on available community resources.
•Maintained knowledge of community agencies and
community resources for referrals and care
partnerships, and utilizes these to meet patient
needs.
•Interviewed, assesses needs, and refers
patients/families to resources for social, emotional,
or financial assistance when appropriate, and serves
as a patient advocate to help in decision-making
process.
•Assisted and facilitates multidisciplinary team in
understanding and integrating these aspects into
plan of care.
•Served as liaison between providers, care setting,
patient's social support system, and Department of
Social Services during evaluation/investigation.
•Reported suspected cases of child and/or adult
abuse, neglect, and exploitation.

Utilized advanced conflict resolution skills to identify
problems, recommend solutions, and work toward
resolution.
•Initiated insurance authorizations for acute care
settings

• Coordinated with physicians to create care plans for
  all patients.
  •Enrolled newly diagnosed patients into Ryan White
  Program.
  •Educated newly diagnosed patients about
  medication compliance and HIV Education.
  •Provided HIV counseling and review safer sex
  practices with patients.
  •Referred patients to mental health, housing and
  community resources.
  • Reintegrated patients who have fallen out of care.
• Completed RW enrollment process with patients
  every six months.

• Created and maintained a comprehensive social
  service program within facility.
  •Facilitated Care Plan meetings with stakeholders.
• Supervised staff whether directly or indirectly in
  accordance with company policies and
  procedures.
  •Coordinated discharge plan with insurance
  companies representatives in person (weekly)
  (Highmark, Cigna, UPMC, Coventry).
  •Reviewed benefits and coverage and insurance
  plans for SNF stay with residents.