- Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care: Recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient.
- The PACT RN Care Manager is responsible for collaborating with services internal and external to VA Health Care Services to facilitate care transition in order to effectively meet the patients' needs and provide a interdisciplinary approach to care.
- The PACT RN Care Manager uses the nursing process and evidence-based practice to triage walk-in patients and collaborate with the team (Patient, Primary Care Provider, other RN Care Managers, LPN, and MSA) and larger team (family/caregiver, internal and community based services involved in providing care to the patient) in developing the patient-driven holistic plan for life.
- The PACT RN Care Manager provides patient and family health education with a focus on self-management, shared decision making, prevention, and wellness, based on the individual patient's goals.
- Manages a designated panel of patients and utilizes VA developed protocols to enhance preventions as well as manage chronic diseases including HTN, DM, COPD, CHF.
- Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems via face-to-face visits, virtual video connect, secure messaging and telephone calls.
- Collaborates with patients to assess and identify needs, issues, care goals, and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness.
- Partners with Veteran to support self-management, prevention, and wellness, utilizing a Whole Health approach to care and Motivational Interviewing to assist with behavior change and and support his or her goals.
- Conducts follow up calls to hospitalizations and Emergency Department visits, reviews records, and coordinates follow up care.
- Demonstrates ability to collaborate with all levels of services and disciplines. Collaborates with patient, family and care providers in any and all settings where care is being provided to evaluate and update changes in the patient-driven life plan and patient management.
- Reviews options with patients and families, including costs, alternatives, risks/benefits and services.
- Performs other duties as assigned.
Registered Nurse - Oconomowoc, United States - Department Of Veterans Affairs
Description
Summary
The new 8,500-square-foot VA facility at 1289 Olympia Fields Drive in Oconomowoc, WI expands access to VA care for Veterans in Milwaukee's western suburbs and provides another convenient option where they can receive outpatient services.
Duties
The Primary Care RN practices as a Care Manager and is a member of the Team and provides patient-centered, evidence-based, patient driven care in all patient interactions across the care continuum. The RN Care Manager 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 conducts a comprehensive assessment of patients' needs and provides patient and family health education with a focus on self-management, prevention, resources, and wellness, based on the patient's needs/goals. The RN Care Manager demonstrates leadership by serving as an advocate for patients, and a team leader with colleagues as she/he continues to enhance his/her own and the team's professional growth, development, and practice.
MAJOR DUTIES AND RESPONSIBILITIES:
Pay: Competitive salary, regular salary increases, potential for performance awards
Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Licensure: 1 full and unrestricted license from any US State or territory
Work Schedule: Days - Full Time
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