Bedford VA is a Level 3 interdisciplinary teaching facility with service-lines serving rehabilitation, long term care and mental health inpatients and outpatients, with multiple community-based outpatient clinics (CBOC). There is a large outpatient psychiatric population, with admissions for medical co-morbidities. Home-Based Primary Care is provided in the veteran's home. Community-based outpatient clinics (CBOC) RN Care Coordinator: The responsibilities include, but are not limited to the following description: Participates in daily huddles, weekly pre-planning and monthly team meetings with core members of the PACT team. Relays relevant information to PACT/interdisciplinary team. Coordinates care by working across care settings to assist patients and ensure they receive the necessary care. Assists with care coordination and case management internally and externally. Monitors patient's treatment plans to ensure there is no lapse in care. Uses appropriate data sources for panel management. Ensures release of information (ROI) is obtained and properly documented in the health record. Utilizes clinic slots appropriately, maximizing patient flow. Triages patients as needed. Monitors patients at high risk for hospitalization and keeping the Primary Care Provider (PCP) apprised of clinical issues needing provider intervention. Provides post discharge and emergency room telephone calls to team panel to ensure safe transitions in care, assessing current needs and appointing as needed for follow up care. Collaborates with internal and external services to facilitate care transition in order to effectively meet the patient's needs. Properly utilizes all methods of care delivery to include video and telehealth. Collaborates with the Nurse Manager; creating a positive work environment which enhances care delivery and professional development of clinically competent staff. Manages consults and patient inquiries (electronic or telephone) expeditiously May be required to cover other facilities as needed. Work Schedule: Monday - Friday, 8:00am -4:30pm Work Location: Haverhill VA Clinic, 209 Summer Street, Haverhill, MA 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.