The Registered Nurse will function as the High Rick Care Manager/Patient Educator in Harlingen, Texas. You will use the nursing process and evidence-based practice to collaborate with the Teamlet, extended Team and external members (family/caregiver and community-based services involved in providing care to the patient) to meet patient needs. Provide patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. You will provide patients with personalized, proactive, and patient-driven health care through such activities as assisting in developing a personal health plan, listening to the patient and addressing their needs/goals, engaging in scheduling group appointments, encouraging and supporting Telehealth modalities, and creating an environment that benefits the veteran. Assure the delivery of patient centered care to all patients and employs population health management principles to optimize health and wellbeing for the patient through such activities as use of evidenced-based practice recommendations, completing clinical reminders, tracking high risk behaviors, maintains an awareness of access according to third next available appointments, assisting the patient to develop coping mechanisms, and assisting the patient to identify health care goals and actions to take to meet those goals and evaluating progress. Demonstrate advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care. Triage and apply a collaborative team approach in identifying, analyzing, and resolving patient care problems. Provide both indirect and direct patient care in collaboration with the interdisciplinary team; serve as clinical resource expert; and function as an educator for the team and patient. Care management of ACSC patients transitioning from a hospital setting to a lower level acuity setting that are both assigned and unassigned to a Valley Coastal Bend. Provide assistance with management of non ACSC patients both assigned and unassigned to Valley Coastal Bend. You will function as a systems coordinator; monitor progress and intervene as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitor progress along clinical pathways, analyzes variations and initiates appropriate actions. Educate patients in the utilization of MyHealtheVet and the Secure Message portal. If patient is not registered, website information is given along with MyHealtheVet authenticators within respective clinic. Maintain current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. You will promote health promotion and risk reduction strategies for the PACT Teamlets through their assessment and utilization of ACSC conditions, HEDIS performance measures, utilization of the Primary Care Almanac, Primary Care Compass, eQM, VCB DataMart, Intelligent Preventive Care App and EPRP data. Work Schedule: Full-time 8:00am-4:30pm; partial telework Financial Disclosure Report: Not required
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.