Sarah Evans
Bli Bli,QLD
Summary
Dedicated Clinical Nurse with experience delivering nursing care to propel desired patient outcomes. Expert at geriatric care planning, colleague communication and administering direct patient care. Compassionate patient advocate and quick-thinking problem solver with excellent judgment.
Overview
17
17
years of professional experience
Work History
Case Manager - Residential
Transition Care Program, Qld Health
Sunshine Coast , Qld
02.2025 - Current
- Advocated for clients by obtaining information regarding treatment options and clinical status.
- Educated clients and their families about their rights and available community resources.
- Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
- Assessed and identified service delivery challenges and opportunities within local area.
- Counseled clients on available resources within the community that could help meet their needs.
- Compiled reports on cases and submitted them to supervisors as required.
- Collaborated with medical professionals to coordinate treatment plans for clients.
- Handled administrative procedures to meet objectives set by boards of directors or senior management.
- Provided case management services including intake, assessment, crisis intervention, advocacy, referral and monitoring of families.
- Prepared and presented case reports and summaries to stakeholders and management.
- Coordinated transportation services for clients who lacked access to reliable transportation.
- Collaborated with multidisciplinary teams to provide holistic support to clients.
- Identified barriers to client success and developed strategies to overcome them.
- Participated in interdisciplinary team meetings to discuss treatment options.
- Transitioned clients to different providers based on progress or needs.
- Provided referrals to appropriate health care providers or other community resources.
Discharge Coordinator Clinical Nurse
Queensland Health
Sunshine Coast , Qld
02.2023 - Current
- Provides comprehensive discharge planning services to patients and families.
- Facilitates communication between hospital departments to ensure timely discharge of patients.
- Assists with the coordination of post-discharge services such as home health care
- Monitors patient progress throughout their stay in the hospital setting.
- Collaborates with physicians, nurses, social workers and other healthcare professionals to coordinate efficient discharges.
- Conducts pre-discharge meetings with patients and families to discuss aftercare plans.
- Acts as a resource person for family members providing support during patient's hospital stay.
Clinical Nurse/Case Manager
Transition Care Program, Qld Health
Sunshine Coast, Qld
01.2024 - 02.2025
- Coordinated with healthcare team members to assess, plan and evaluate patient care plans.
- Utilized critical thinking skills when making decisions about patient care needs.
- Developed and maintained departmental policies, procedures or patient care standards based on evidence-based practice guidelines or expert opinion.
- Developed teaching plans for patients regarding self-care management techniques for chronic illnesses or rehabilitation goals.
- Facilitated discharge planning by collaborating with social workers or case managers.
- Maintained patient records and verified patient privacy and clinical compliance to minimize data breaches.
- Participated in quality improvement initiatives to ensure best practices were followed.
- Consulted other health care providers in patient discharge, patient care or clinical procedures.
- Demonstrated effective communication skills when interacting with patients, family members, physicians, nurses and other healthcare providers.
- Utilized strong assessment skills to determine necessary patient care.
- Collaborated with other health care professionals and service providers to drive optimal patient care.
Clinical Nurse/Case Manager
Transition Care Program Sunshine Coast
Nambour, Qld
08.2022 - 01.2023
- Provided post-operative care and education to patients and families.
- Collaborated with physicians and other healthcare professionals to develop individualized treatment plans for each patient.
- Maintained accurate records of patient care, condition, progress, and concerns.
- Coordinated multidisciplinary team meetings to discuss patient progress and issues.
- Developed teaching plans for patients regarding self-care management techniques for chronic illnesses or rehabilitation goals.
- Counseled patients on health maintenance and disease prevention strategies.
- Utilized critical thinking skills when making decisions about patient care needs.
- Demonstrated effective communication skills when interacting with patients, family members, physicians, nurses and other healthcare providers.
- Utilized strong assessment skills to determine necessary patient care.
- Educated patients and family members about preventive health care and recovery.
- Carried out comprehensive care focused on patient needs and meeting care goals.
Clinical Case Manager
West Moreton Transition Care Program
Ipswich, Qld
11.2021 - 08.2022
- Conducted regular home visits to review and monitor care plans based on clients' needs and program requirements.
- Monitored and evaluated delivery of services to clients to maintain quality care.
- Encouraged clients to articulate expectations and goals for successful rehabilitation.
- Provided case management services including intake, assessment, crisis intervention, advocacy, referral and monitoring of families.
- Educated clients in navigating complex health care systems to prevent uncertainty and discontinuities of health care.
- Transitioned clients to different providers based on progress or needs.
- Initiated patient and family education and discharge planning at admission.
- Adhered to ethical principles and standards to protect clients' confidential information.
- Linked clients with social services, health care providers and governmental agencies to help claim or reclaim individual autonomy.
- Maintained up-to-date case records with case activity status.
- Utilized facility database systems to update patient records, transmit prescriptions and transfer files.
Clinical Nurse
Blue Care Community
Lowood/Rosewood, Qld
03.2008 - 11.2021
- Manage team of Registered and Enrolled Nurses working in the Community
- Cared for patients with various wounds caused by injuries, medical treatments and diseases.
- Conducted wound assessments for patients and documented information.
- Worked with healthcare teams to assess patients, manage wounds and monitor healing.
- Educated patients and family members on cleaning and dressing wounds and identifying signs of infection.
- Undertook Continence assessments, including MASS and CAPS applications, using MASS-eApply online applications.
- Liaise with referrers - hospital discharge staff, GP's RAS Assessors, brokerage with other providers and ensure smooth admission process
- Undertook Continence assessments, including MASS and CAPS applications using MASS-eApply online applications.
- Coordination of Client care to achieve positive Client experience and ensure that their care was Person Centered
- Held the Portfolio of Infection Control
- Assisting with Quality Management Processes (Audits, Client documentation, incidents, complaints and compliments)
- Interviewing RN applicants and supporting new staff through orientation process and ongoing
- Annual PDR's for Nurses
- Knowledge of different funding bodies -CHSP, NDIS, HCP, DVA, PAC, Self Funding
- Understanding of My Aged Care
- Carried out comprehensive care focused on patient needs and meeting care goals
- Chaired monthly staff meetings and delivered education (TAE40110 Cert IV)
Skills
- Intake and discharge
- Team Supervision
- Patient care delivery
- Quality assurance controls
- Acute and chronic health issues
- Nursing education
- Quality improvements
- Work ethic
- Rehabilitative care
- Healthcare management
- Diabetes management
- Continence assessment experience
- Discharge planning
Referrees
Leesa Smith 0448 327 007
Program Manager, Community Connect, Sunshine Coast
Jenny Sargent 0407 125 779
CNC, Transition Care Program, Sunshine Coast
Jennifer Marshall 0437 013 070
Nurse Unit Manager, Aged Care Assessment Team/ Transition Care Program
Older Persons, Div. of Medicine. West Moreton.
Timeline
Case Manager - Residential
Transition Care Program, Qld Health
02.2025 - Current
Clinical Nurse/Case Manager
Transition Care Program, Qld Health
01.2024 - 02.2025
Discharge Coordinator Clinical Nurse
Queensland Health
02.2023 - Current
Clinical Nurse/Case Manager
Transition Care Program Sunshine Coast
08.2022 - 01.2023
Clinical Case Manager
West Moreton Transition Care Program
11.2021 - 08.2022
Clinical Nurse
Blue Care Community
03.2008 - 11.2021