Uses the nursing process and evidence-based practice to collaborate with the Teamlet and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing and patient -driven holistic care plan for life. Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. - Follows the patient's personalized health care plan as designated by the patient and Patient Aligned Care Team (PACT). - Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care - Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. - Provides indirect patient care in collaboration with the interdisciplinary team; serves as clinical resource expert; and functions as an educator for the team and patient. - Functions as a systems coordinator; monitors progress and intervenes as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitors progress along clinical pathways, analyzes variations and initiates appropriate actions. - Is a role model in the provision of excellent customer service. - Reviews Message Manager and assist Team to address/complete pending alerts communicated throughout tour of duty to facilitate care and address needs of the caller within 48 hours. - Completes and documents Nursing Notes in CPRS, as applicable, in a timely manner and closes the Encounter Notes for patients not seen by a provider. Notes will be closed by the end of tour of duty daily. Areas to be addressed include: Encounters: reasons for visit-Service Connection; Primary assignment-Service connected conditions under the Diagnosis tab; Procedures, ACSC conditions, etc. - Provides Care Management to patients with Ambulatory Care Sensitive Conditions (ACSCs) including reviewing the patient record, decide if the patient needs more in-depth education (formal and/or informal); nursing visits and/or telephone calls between provider visits to assist in care management. Collaborates with the High Risk Care Coordinators, Home Telehealth, social work, and/or dieticians for referrals and care management. - Complete the Blood Glucose meter check daily, as applicable. After completing quality check, if applicable, and entering correct patient information for testing. - Completes and documents secure messaging within 72 hours. Surrogate is identified at all times. Escalation of secure messaging must be maintained at 10% or less. Diverts messages to appropriate care lines as needed. Alerts MyHealtheVet coordinator for assistance to prevent incomplete or escalation of messages. - Provides 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 group appointments, encouraging and supporting Telehealth modalities, and creating an environment that benefits the veteran. Other Duties as assigned. Work Schedule: Monday-Friday, 8:00am-4:30pm 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
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.