The Patient Aligned Care Team (PACT) Registered Nurse (RN) CARE MANAGER is assigned to ACOS/Primary Care Services which provides outpatient primary and specialty care in the out-patient clinic setting. Patient populations include male, female, and transgender Veterans from age 18 to older. Primary Care provides the following care to Veteran Patients: medical/surgical annual examinations, evaluation and management of acute illnesses and injuries, preventative medicine including immunizations, health maintenance screening examinations, Department of Transportation examinations, chronic disease management, population health management, patient/care giver education, pain management, whole health, coordination of care with intra-facility departments, coordination of care with outlying community partners, coordination of care with other Veteran Health Administration facilities, and emotional support. As member of the interdisciplinary team, the PACT RN executes position responsibilities that demonstrate leadership, experience, and creativity in performing a variety of duties, including supporting the primary care provider (PCP) in managing assigned patients. The PACT RN (depending on education, experience, and competency) may be assigned other responsibilities as a preceptor, educator, or charge nurse. The PACT RN may be required to participate in performance improvement work-groups and or committees representing Primary Care Nursing. The RN PACT Care Manager applies the Patient Aligned Care Team (PACT) principles utilizing the nursing process and evidence-based practice to collaborate with the Teamlet (Patient, Primary Care Provider, RN Care Manager, Clinical Associate or Licensed Practical Nurse, and Clerical Associate) and expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven care plan for life. The RN Care Manager is a member of the Teamlet team. The RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate care transition to effectively meet the patients' needs. The RN Care Manager provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RN Care Manager demonstrates leadership by serving as an advocate for patients, and a team leader with colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. The RN PACT Care Manager follows the Primary Care Handbook (VHA Handbook 1101.10) and VHA Directive 1406, Patient Centered Management Module (PCMM) for Primary Care. Provides Health Coaching to enhance the patient's wellbeing and achieve their related health-related goals per VHA Handbook 1120.02, Health Promotion and Disease Prevention Core Program Requirements. Provide Health Education as defined in VHA Handbook 1120.04, Veterans Health Education and Information Core to enhance the quality of life through health promotion and disease prevention, actively partner with their health care teams and engage needed family and social support systems while developing self-management and coping skills, and utilizing appropriate VHA health care resources. Establish Home Telehealth monitoring using case management principles to coordinate care using health informatics, disease management, and telehealth technologies to facilitate access to care and to improve the health of Veterans to improve clinical outcomes. Provides primary care that is patient-centered, data driven, continuously improving, team-based, accessible, timely, comprehensive, coordinated, and provides continuity of care over time. Which is personalized, proactive, patient-driven health care. The RN PACT Care Manger acts in advance of a likely future situation, rather than just reacting by taking initiative to act rather than just adjusting to a situation. Provide patient-driven engagement with the patient being the source of control, ensuring that their health care is based on their needs, values, and life preferences. Building a relationship between the patient and health care team. Provides Veterans with health education which spans the continuum of care from the skills and information needed to promote health and prevent disease, to the patient education needed to cope with and manage acute and chronic conditions. Clinical preventive services are delivered for the primary prevention of disease, or for the early detection of disease in persons who are asymptomatic for the target condition, with the goal of preventing or minimizing future morbidity and mortality. Work Schedule: Monday through Friday 8:00 am to 4:30pm; or as agreed upon by Supervisor Financial Disclosure Report: Not required
Internal Number: 599307300
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.