The RN Care Manager is a member of the Teamlet team and 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 Manager uses the nursing process and evidence-based practice to collaborate with the Teamlet (Patient, Primary Care Provider, RN Care Manager 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. Other duties and responsibilities of the RN Care Manager include but are not limited to the following: Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the
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