This position is located at the Jonathan M. Wainwright Memorial VA Medical Center, La Grande CBOC. The RN Care Manager uses the nursing process and evidence-based practice to collaborate with the Patient Aligned Care Team (PACT) (Patient, Primary Care Provider, RN Care Manager, Clinical Associate, and Medical Support Assistants) and Expanded 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. The RN Care Manager is a member of the PACT team. 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 incumbent is responsible for providing chronic disease management for patients in collaboration with primary care provider to reduce recurring hospitalization and emergency room visits. The RN Care Manager provides patient and family health education with a focus on self management, prevention, and wellness, based on the patient's goals. The RN Care Manager demonstrates leadership by serving as an advocate for patients, team player to colleagues as she/he continues to enhance his/her own and the team's professional growth, self-development and practice. The RN serves as a preceptor or mentor to colleagues or students to enhance their professional growth, development and practice. Responsibilities and duties include but are not limited to the following: Promotes evidence-based patient-driven care on patient's goals Identify, educate and coach to support self-management, prevention, and wellness, based on patient's goals Uses Care Tool Management (CMT), motivational Interviewing, lifegoals, TEACH for success and other tools as deemed appropriate; to guide patients to establish goals Obtains and completes processing of laboratory specimens per laboratory protocols, including POC testing as assigned Functions as CVT presenter, able to problem solve equipment and technology issues, able to provide complete physical exam utilizing CVT equipment as directed by clinical provider. Soothes transitions by collaborating with multidisciplinary services, internal and external to the VA. Identifies high risk populations/chronic disease tracking and patients through the CAN score, that could benefit from CCHT, HBPC, OEF/OIF, palliative care, hospice, etc. Utilizes VA CMT for tracking these visits as well as other patients, care needs and follow-up. Utilizes VA approved patient care tools regularly and integrates data into nursing care and the care management process (Diabetic Registry, Micromedex, Clinical Key, PACT SharePoint, Opioid Risk Registry, Primary Care Almanac, Clinical Practice Guidelines, and others). Collaborates with key members of expanded team-Health Promotion Disease Prevention Program Manager, Health Behavior Coordinator, MOVE Coordinator, Women's Health and others. Links the patient with local and/or VA services, resources, and opportunities based on the patients' needs. Provides patient care thru scheduled clinic visits, walk-in or urgent visits (triage), group visits, telephone visits, chronic disease management visits. Place orders according to protocol. Completes monthly medication inspection for pharmacy ward stock, orders medications as needed. Completes Clinical reminders (pertinent). Promotes access with non-face-to-face visits when appropriate. Answers patient calls/triages messages timely. Preceptor or mentor to colleagues and/or students. Secure messaging utilized for patient communication. Administers medications in accordance with State and Federal laws, RN Licensure, scope of practice, and local policy. - Performs nursing procedures and assists provider with procedures. Performs Point of Care Lab testing procedures per policy, maintains competency as assigned. POC testing includes: Accucheck, Clinitek, and Coagucheck. Coordinates care (procedures, labs, transitions, teaching, patient visits and needs). Performs other duties as designated/assigned within RN scope of practice. Calls patients within 24 hours following hospital discharge and documents in the Electronic Health Care Record (EHR) Work Schedule: Monday - Friday; 8am - 4:30pm Telework: NOT eligible Virtual: This is not a virtual position. Relocation/Recruitment Incentives: NOT authorized Financial Disclosure Report: Not required Pay: Competitive salary, regular salary increases. Paid Time Off: Annual leave nor Sick Leave is accrued with this appointment Retirement: NO retirement eligibility available Insurance: Federal health/vision/dental/term life/long-term care Licensure: 1 full and unrestricted license from any US State or territory.
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.