The incumbent will be assigned to the Patient Care Service in Eugene, OR. The Home Based Primary Care (HBPC) Registered Nurse specified area of practice will be the provision of primary care services to Veterans in the home setting. HBPC is a component of Geriatrics and Extended Care. HBPC provides comprehensive, physician supervised, interdisciplinary primary care administered to Veterans in their homes. The Home Based Primary Care (HBPC) Registered Nurse Care Manager (RNCM) is a PACT team member who provides comprehensive and coordinated nursing care to an assigned panel of patients. The RNCM collaborates with both VA services and community services, as appropriate, to effectively meet the health promotion or disease prevention, acute, chronic, and long-term needs, based on the Veteran's goals and plan of care with a focus on self-management. The HBPC nurse will be the primary coordinator of services, managing Veterans with multiple complex medical or mental health problems requiring prolonged intervention to maintain or improve status and retard decline. HBPC Registered Nurse, in addition to being a core member of the HBPC interdisciplinary team, functions in the PACT team role as a care manager and is responsible for: (1) Delivering direct nursing care in the home setting. (2) Developing and coordinating the patient's plan of care to include ongoing assessment and re-assessment, care planning, care coordination, monitoring, and evaluating clinical outcomes. (3) Interacting, coordinating and advocating for the patient/caregiver with other relevant parties across a continuum of care, beyond a single episode of care, ensuring seamless transitions. (4) Providing individualized education and support to the patient and caregiver to optimize clinical outcomes and support quality of life decisions. (5) Delegating and supervising the care given to the patient by licensed practical nurses (LPNs) or vocational nurses, and home health technicians, as applicable. (6) Providing intensive care management. (7) Linking Veterans with resources. (8) Coordinating resources for comprehensive care to avoid duplication of services and streamline staff interaction and services with the Veteran. (9) Participating in the development of the individual plan of care at interdisciplinary care meetings for assigned panel of patients. The population of Veterans served includes adults with complex chronic diseases that worsen over time. HBPC provides interdisciplinary care that is longitudinal and comprehensive rather than episodic and focused. HBPC provides cost effective primary care services in the home and includes palliative care, rehabilitation, disease management, and coordination of care. Work Schedule: Monday - Friday, 8:00am to 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.