Julie M. Clark, LSW

• Conducted psychosocial admission assessments within 72 hours of admission to short term rehab unit
• Developed and facilitated goal-oriented care plans with patient and interdisciplinary team to improve residents' quality of life.
• Collaborated with Independent Living team of physician, social work and administration on discharge planning and preventing readmissions
• Educated residents and families on available resources to help inform their long term decisions

• Reviewed clinical, financial and psychosocial information to determine appropriateness of potential admissions to both Southwood at Norwell and Queen Anne Nursing Home
• Facilitated communication between hospital case management, family and facility to ensure smooth admission process
• Provided exceptional customer service during phone and email interactions with patients and their families, addressing concerns promptly and professionally.
• Confirmed Medicare and commercial insurance benefits.

Overseeing Department of Social Services for 5-star, 106 bed skilled nursing facility including:

• Coordinating discharge planning for short term rehab patients, providing appropriate community referrals and DME resources.
• Ensuring patient/family teaching is complete.
• Serving as advocate for patients and families to ensure quality of care.
• Educating staff on patient rights.
• Identifying areas in need of improvement as part of QAPI team.
• Collaborating with Psych Services NP and LICSW to create appropriate care plans to address behaviors and psychosocial concerns.
• Completing all required documentation including admission and quarterly assessments and relevant MDS sections.
• Serving as case manager for patients with managed care insurance and ACOs, providing clinical updates and coordinating length of stay.

Oversaw Department of Social Services for 110-bed rehab and skilled nursing facility including:

• Providing direct intervention to residents and residents' families to ensure that their psychosocial needs are being met.
• Leading Interdisciplinary meetings with residents and families at admission, quarterly and at discharge.
• Providing advocacy for appropriate care and treatment of residents as well as educating residents, staff, and families regarding residents’ rights.
• Consulting with long-term care ombudsman as needed.
• Coordinating discharge planning.
• Responsible for timely completion of PASRR screenings, psychosocial assessments, relevant MDS sections and ongoing documentation.

Worked with residents, families, and staff to provide information, advocacy, and support to improve residents’ quality of life and care, including:

• Completing relevant MDS sections and progress notes to address residents’ appropriate treatment needs.
• Conducting person-centered social history and psychosocial assessments to identify residents’ social, emotional, and psychological needs.
• Participating in development of residents’ written interdisciplinary care plan to address and monitor their psychosocial needs, including social work interventions to meet their goals.
• Conducting quarterly interdisciplinary care plan meetings with residents and families to share residents’ progress and problem solve solutions to address ongoing needs.
• Assisting long term residents and families with facility transition at time of admission and throughout placement.
• Receiving, investigating, and resolving resident grievances in accordance with facility policies and best practices.

Provided insight into appropriate design of long-term services and supports for elders and people with diverse disabilities, including:

• Conducting web-based research and literature reviews to identify best practices in system design, such as in person-centered functional assessments, care coordination, and quality improvement strategies.
• Supporting development of competitive proposal narratives, including creating preliminary drafts and providing subsequent edits.

Promoted from Case Manager and Family Caregiver Support Program Care Advisor Assumed wide range of case management and supervisory roles to support elders in their homes and communities, including:

• Conducting in-home needs assessments with elders and caregivers to determine level of support needed to remain safely at home.
• Providing comprehensive assessment of elders’ caregiver needs, including identifying need for supportive care, respite, and other services.
• Educating elders and caregivers and linking them to community resources and public benefits, including housing, Medicaid, food stamps, fuel assistance, and Veterans’ benefits.
• Developing individualized care plans and connecting elders and their caregivers to resources to assist in short term and long-term planning for aging in place.
• Participating in multidisciplinary teams of nurses, protective service workers, and community providers to develop, coordinate, and monitor elders’ service plans.
• Coordinating and monitoring, in direct partnership with elders, caregivers, and providers, on-going service provision.
• Supervising Case Managers to ensure timely assessments, home visits, service coordination, and health and welfare monitoring.