The Home Telehealth Registered Nurse Care Coordinator coordinates care for a panel of patients through-out the continuum of care for a variety of health conditions. The HT RN Care Coordinator works closely with program staff, the primary care provider (or providers), other healthcare professionals and team members, other clinics, internal or external services and community agencies, and medical center leadership. Duties May Include However Are Not Limited To The Following: The incumbent will coordinate care for a panel of patients through-out the continuum of care for a variety of health conditions including, but not limited to: hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, post traumatic stress disorder, dementia, depression/anxiety, bipolar disorder, schizophrenia, and weight management. Supervisory Control: The RN HT Care Coordinator is directly responsible to the Connected Care Program Manager, under the Nurse Executive. The RN HT Care Coordinator is additionally professionally and clinically responsible to the collaborative functioning of the Home Telehealth team. Functions and Responsibilities The RN HT Care Coordinator performs a full range of administrative and clinical duties, participates in complex clinical and technical decision-making, and assures the implementation and maintenance of standards for HT practice in their specified program. The individual provides leadership that is characterized by continuous responsibility and accountability for information and practice guidelines that impact patient care. The individual provides leadership as a nursing consultant in improving and sustaining the quality, safety and effectiveness of HT related processes which involve regular communication with clinical, administrative and technical staff both within the VA and with external organizations/vendor. The RN HT Care Coordinator exhibits leadership in providing safe patient care related to HT. Through instruction, consultation, collaboration, clinical and administrative responsibilities, the individual serves as a clinical resource for VA staff within his/her local area, i.e., medical, nursing, administrative, technical and management staff and the community in HT related performance improvement outcomes. Competency will be evaluated annually. The RN HT Care Coordinator uses the nursing process and evidence-based practice to collaborate with the PACT team members (Patient, Primary Care Provider, PACT nurses, Program Support Assistant (PSA), and LPN) and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. The RN HT Care Coordinator is responsible for collaborating with services internal and external to the VA to facilitate care transition in order to effectively meet the patients' needs. The RN HT Care Coordinator provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RN HT Care Coordinator demonstrates leadership by serving as an advocate for patients, team player to colleagues as she/he continues to enhance his/her own and the team's professional growth, development and practice. Duties & responsibilities include but are not limited to: Provides initial and ongoing assessment of patients to identify needs issues, care goals and appropriate resources necessary for care management. Assures accuracy of information provided in the forms of progress notes, reports, presentations, and briefings on program patients and operations. Provides leadership in application of the nursing process and identifies resources and critical factors for achieving desired outcomes for discharge, post hospitalization recovery and health maintenance/improvement. Sets clinical care goals, short and long term, in collaboration with patient, provider(s), and family members. Functions as a systems coordinator for the plan of care; monitors progress through the expected hospital course and intervenes as appropriate to facilitate achieving patient outcomes within anticipated timeframes. Coordinates care and discharge planning with the patient's primary care provider and team. Collaborates with patient and care providers in all settings where care is being provided to evaluate and update changes in the therapeutic plan of care and patient management. Recognizes complex situations that impact patient care and intervenes, using sound judgment, professional attitude and appropriate channels. Recognizes impact of age-specific care needs and incorporates this into the assessment process. Also, incorporates these age-specific needs into care as reflected by modification of treatment plans. Maintains a working knowledge of resources available in the community. Appropriately documents own interventions and oversee appropriate health team documentation of patient care. Work Schedule: Mon-Fri 7:30am-4:00pm This position currently requires rotating weekends on standby call in support of Covid-19 monitoring. Financial Disclosure Report: Not required
Internal Number: 600128500
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.