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 the 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). Promotes and 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. Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Provides direct or 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 for the plan of care; monitors progress and intervenes as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitors progress of standing orders, analyzes variations and initiates appropriate actions. Is a role model in the provision of excellent customer service. Reviews Message Manager and assists 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. Assures Nursing Staff closes encounters. Areas to be addressed include: Encounter: reasons for visit; Service Connections; Primary assignment; Service Connected conditions under the Diagnosis tab; Procedures; etc. Supports/assists staff to provide care management to patients with Ambulatory Care Sensitive Conditions (ACSCs) including reviewing the patient record, deciding 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. Monitors progress with standing orders and/or pathways, analyzes variations and initiates appropriate actions. Maintains current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. Reviews options with patients and families, including costs, alternatives, risks/benefits and services. Actively educates the patient and family on disease process, resources, plan of care, treatments and /or procedures. Advocates fiscal responsibility in the management of patient care through effective utilization of resources. 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.