The HCC RN Care Manager must be self-motivated, organized, flexible, responsible, and empathetic. The HCC RN Care Manager must possess and demonstrate excellent critical thinking skills and excellent nursing assessment skills. The RN is responsible for assessing and continually reassessing the needs of veterans and caregivers. Incumbent is clinically/administratively responsible to the Division Nurse Manager/Program Director where assigned. The RN provides initial and continued assessment of nursing needs of the patients, evaluate cardiopulmonary status of patients, teaches the patients and caregivers effective and efficient ways of managing and delivering care in the home monitors the patients' condition and the care provided in the home, provides direct nursing care - to include but not limited to: wound care and extensive patient teaching. Work Schedule: Monday to Friday 8:00am to 4:30pm; to meet the needs of the patient and program needs. Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required The major duties and responsibilities include, but are not limited to: Demonstrated clinical competencies in such areas as age-specific care, cultural assessment, and health education. An ability to effectively function autonomously, as well as a member of an interdisciplinary team Respect for cultural and spiritual values. A commitment to discipline-specific standards of practice, including: ethical conduct, the primary care delivery model, chronic disease management, palliative care, principles of care management, a holistic framework of practice, and geriatric care skills (including infection control, equipment and environmental safety). Determine the appropriateness of patients for admission into the HCC Program. Help develop patient treatment plans based on a comprehensive interdisciplinary assessment of the patient and the caregiver. Implement the patient's treatment plan through home visits. Review the patient's progress as a team at regular intervals, at least twice weekly, or when there is a change in the patient's condition. Assess and support the caregiver's capability to continue to provide care. Educate the patient and the caregiver. Coordinate the process of care with the other team members to maximize efficiency. Assess the patient's continuing need for HCC care, and plan for HCC discharge when indicated. Document all patient care activities in a timely manner (per facility policy). Identify areas for continuing education and participate in in-service training (including staying current with all required education). Participate in developing and implementing the performance improvement plan (including quality monitors). Instruct students of various disciplines in the challenges encountered in delivering health care in the home setting. Serve as a role model in the effective operation of an interdisciplinary team. Participate in the development and periodic review of the local HCC Policy and Procedure Manual. Utilize VHA and community resources as appropriate. Participate in HCC team meetings. Case management of approximately 30 patients.
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.