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Registered Nurse (PACT)

Company: Veterans Affairs, Veterans Health Administration
Location: McAllen
Posted on: June 5, 2021

Job Description:

The Registered Nurse will serve as the PACT Care Manager/Coordinator for the McAllen Outpatient Clinic. You will use the nursing process and evidence-based practice to collaborate with the Teamlet and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing and patient -driven holistic care plan for life. [ "You will provide patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. Follow the patient's personalized health care plan as designated by the patient and Patient Aligned Care Team (PACT). Demonstrate advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care. Triage and apply a collaborative team approach in identifying, analyzing, and resolving patient care problems. Provide indirect patient care in collaboration with the interdisciplinary team; serves as clinical resource expert; and functions as an educator for the team and patient. Function as a systems coordinator; monitor progress and intervene as necessary to ensure that patient outcomes are achieved within anticipated timeframes. Monitor progress along clinical pathways, analyze variations and initiate appropriate actions. Review Message Manager and assist Team to address/complete pending alerts communicated throughout tour of duty to facilitate care and address needs of the caller within 48 hours. Complete and document Nursing Notes in CPRS, as applicable, in a timely manner and close the Encounter Notes for patients not seen by a provider. Notes will be closed by the end of tour of duty daily. Areas to be addressed include: Encounters: reasons for visit-Service Connection; Primary assignment-Service connected conditions under the Diagnosis tab; Procedures, ACSC conditions, etc. You will provide Care Management to patients with Ambulatory Care Sensitive Conditions (ACSCs) including reviewing the patient record, decide if the patient needs more in-depth education (formal and/or informal); nursing visits and/or telephone calls between provider visits to assist in care management. Collaborate with the High Risk Care Coordinators, Home Telehealth, social work, and/or dieticians for referrals and care management. Promote health promotion and risk reduction strategies for their PACT teamlet through the assessment and utilization of the SAIL performance measures, ACSC conditions, HEDIS performance measures, utilization of the Primary Care Almanac, Primary Care Compass, EQm, DataMart, and EPRP data. Complete PACT specific data training annually. Actively lead/participate in daily huddles addressing the following key elements of: PC Think-utilizing the Patient Appointment Planning tool, addressing clinical reminders for patients being seen that day, community care needs for team patients, HEDIS performance scores, current projects focused on improvement, and daily announcements. Work Schedule: Full-time Monday-Friday; 8:00am-4:30pm\nFinancial Disclosure Report: Not required" ]

Keywords: Veterans Affairs, Veterans Health Administration, McAllen , Registered Nurse (PACT), Other , McAllen, Texas

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