The Registered Nurse is responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements and evaluates care based on age-specific components. Assumes responsibility for the coordination of care focused on patient transition through the continuum of care, patient and family education, patient self-management after discharge, and supporting factors that impact customer satisfaction. Duties and responsibilities for the Registered Nurse, High Risk Care Manager/Patient Education include, but are not limited to the following: Uses the nursing process and evidence-based practice to collaborate with the Teamlet, extended Team and external members (family/caregiver and community-based services involved in providing care to the patient) to meet patient needs. Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. Is a role model in the provision of excellent customer service. 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 scheduling 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 across the continuum of care. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Provides both indirect and direct patient care in collaboration with the interdisciplinary team; serves as clinical resource expert; and functions as an educator for the team and patient. Care management of ACSC patients transitioning from a hospital setting to a lower level acuity setting that are both assigned and unassigned to a Valley Coastal Bend. Provide assistance with management of non ACSC patients both assigned and unassigned to Valley Coastal Bend. 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. Educates patients in the utilization of MyHealtheVet and the Secure Message portal. If patient is not registered, website information is given along with MyHealtheVet authenticators within respective clinic. Maintains current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. Collaborates with patient and care providers in any and all settings where care is being provided to evaluate changes in the patient-driven life plan and patient management. Reviews options with patients and families, including costs, alternatives, risks/benefits and services. Actively educates the patient and family on health promotion and disease prevention strategies, disease specific conditions, and other health care related topics. Advocates fiscal responsibility in the management of patient care through effective utilization of resources. Screens patients for social service, home care, and other community care needs; and coordinates or makes referrals as appropriate; and seeks consultation when indicated. Completes APS reports as indicated. Appropriately documents own interventions and oversees appropriate health team documentation of patient care. Keeps patient's provider and appropriate case manager aware of patient progress, issues, and/or problems. Evaluates needs and facilitates the patient's ability to learn the principles of self-care; utilizes appropriate resources if the patient is unable to grasp the knowledge/skills needed for self-care. Actively participates in care delivery with priority attention to patient preference. Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Assures the delivery of patient centered care to all patients and employs population health management principles to optimize health and wellbeing for the patient through such activities as use of evidenced-based practice recommendations, completing clinical reminders, tracking high risk behaviors, maintains an awareness of access according to third next available appointments, assisting the patient to develop coping mechanisms, and assisting the patient to identify health care goals and actions to take to meet those goals and evaluating progress. Other duties as assigned Work Schedule: Monday-Friday, 8:00am - 4:30pm 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.