The Home Based Primary Care (HBPC) Registered Nurse provides primary care services for Veterans who have a number of chronic medical conditions requiring longitudinal case management by an interdisciplinary team in the home environment. Patient populations include male and female, adult and elderly, frail patients. Duties may include, but are not limited to: Provides oversight of the patients' journey through the continuum of care, ensuring that all steps in the process are coordinated, timely and completed- tracking the overall access to services. Provides Veteran centered care and formulate a care plan which incorporates and reflects the Veteran's health care goals. Functions as an expert in clinical practice to the assigned roles and responsibilities. When appropriate, provide services through palliative care model of care. Uses a team approach to provide interdisciplinary case management to Veterans meetings eligibility criteria for HBPC. Provides Veteran, family, and staff education and support. Guides, develops, and supports staff from a leadership perspective. Assesses the Veterans status and identifies priority needs for care throughout the health care continuum. Provides community agencies with patient information on a "need to know" basis, according to VA policies and procedures always respecting patients' privacy and confidentiality. Anticipates emergences, coordinates prevention, and evaluates responses through critical analysis of patient situations. Assesses the complex learning needs of specific patient/family cohorts. Uses appropriate consultants, integrates recommendations into teaching plans and assures appropriate follow up. Leads and organizes delivery of care to assure continuity of care and peer accountability for practice, including access to care and discharge planning. Maintains HBPC program practice-specific and specialized competencies. Provides leadership using own expertise to assess, maintain, or improve competence of other staff. This may be completed by precepting new nursing employees, student nurses, or providing peer training. Travels to each Veteran's home through HBPC's assigned service as needed/directed by interdisciplinary care team to provide quality care. Develops and implements routine patient monitors. Shares information related to new technology, procedures, medication, trends and practices with co-workers and students. Delivers complex patient care situations in patients' home and serves as a liaison between patients, families, VA staff and community agencies. Coordinates referrals for multiple home services, including but not limited to RN, social work, and physical therapy. Some referrals can be made within the HBPC program and others are made through HCBS for care in the home environment. Maintains knowledge about VA and HCBS program eligibility. Works closely with VA staff and community agencies to resolve resource challenges to meet patient safety and therapeutic needs. The Scope of Practice of the Registered Nurse is defined in the four dimensions outlined in the Nurse Qualification Standard (this will be provided to employee during orientation). Maintain safe working environment and perform infection control measures. Appropriately use equipment and supplies per manufacturing guidelines and best practices. Maintain safe, orderly work areas. Report any accident to self or patient, fills out appropriate form. Follows Life Safety Management (fire protection) procedures. Reports safety hazards, accidents and injuries. Reviews hazardous materials/Safety Data Sheets (SDS)/waste management. Follows Emergency Preparedness Plan. Follows security policies/procedures. Complies with federal, state and local environmental and other requirements preventing pollution, minimizing waste, and conserving cultural and natural resources. Demonstrates infection control practices for disease prevention (i.e. hand washing, universal precautions/isolation procedures, including TB requirement/precautions. The incumbent implements, and monitors OSHA goals related to Life Safety Management, health and the environment procedures. Reports safety hazards, accidents and injuries. Implements, monitors and reviews hazardous materials/Material Safety Data Sheets (MSDS)/waste management, fire protection. Implements and monitors Emergency Preparedness plan. Implements and monitors security policies/procedures. The incumbent implements and monitors compliance with federal, state and local environmental and other requirements preventing pollution, minimizing waste, and conserving cultural and natural resources. Participates in Quality Improvement or committees. Other duties as assigned. Work Schedule: Monday-Friday, 0800-1630 (Intermittent) Financial Disclosure Report: Not required Recruitment / Relocation Incentive: Not Authorized Licensure: 1 full and unrestricted license from any US State or territory. Paid Time Off: Annual leave accrued at the rate of one (1) hour per every 10 hours in a paid status; Sick leave accrued at the rate of one (1) hours per every 20 hours in a paid status.
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.