The RN Care Coordinator uses the nursing process and evidence-based practice to collaborate with the Teamlet (Patient, Primary Care Provider, RN Care Coordinator and Clinical Support Technician) 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 Care Coordinator is a member of the Teamlet team. The RN 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 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 Care Coordinator demo
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