Department of Veterans Affairs
The Home Based Primary Care (HBPC) Outpatient Staff Registered Nurse (RN) executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex HBPC care. This nurse provides direct Veteran care and care coordination, as it pertains, to Veterans and their care within the HBPC Program. This position works out of the Joplin Community Based Outpatient Clinic (CBOC).
- RN Duties include but not limited to: Responsible for case management, assessment, triage, Veteran education, resource coordination, medication and treatment coordination, and care planning. This nurse plans and delivers technically competent care in the home of Veterans with complex needs, including health promotion, health prevention, geriatric care, primary care, and palliative care. Utilizes interventions, which maximize health capabilities and reduces unnecessary urgent care and emergency room visits, per Veteran's goals of care. Makes home visits to Veterans in the program. Collaborates in the development, implementation, evaluation, and revision of policies, procedures, and/or guidelines. 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. 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. Providing individualized education and support to the patient and caregiver to optimize clinical outcomes and support quality of life decisions. Delegating and supervising the care given to the patient by licensed practical nurses, and home health technicians, as applicable. Providing intensive care management for assigned patients. Linking Veterans with resources. Coordinating resources for comprehensive care to avoid duplication of services and streamline staff interaction and services with the Veteran. Conducts assessments in the home to develop treatment goals and plans based on comprehensive interdisciplinary assessment of the patient and the caregiver. Participates in the development of the individual plan of care at interdisciplinary care meetings for assigned panel of patients. Implements the plan of care through home visits or Telehealth, as indicated. Reviews progress toward goals at regular intervals, as a team, on a quarterly basis, or more frequently when there is a change in the patient's condition. Assess and support the caregiver's capability to continue to provide care - Assesses clinical data for neurological, cardiac/vascular, respiratory, gastrointestinal, genitourinary, and skin and documents findings and reports abnormalities. Incorporates assessment findings into treatment plan. Coordinates care with other health care providers in assessing, planning, implementing, and evaluating treatment interventions. Coordinates transitions of care from outpatient to inpatient or emergency department settings through communication with outpatient facilities and the interdisciplinary team. Appropriate documentation as established by HBPC Standard Operating Procedures (SOP). Administers medication safely and accurately. Identifies patients at high risk for harm to self and follows established SOPs on Suicide Risk. Establishes and maintains effective communication with patients, family members, and the interdisciplinary team. Assumes responsibility for telecare calls that can be handled by the RN, directing to the physicians those calls that must have physician response. Understands the legal ethical implications of Patient Self Determination Act, Patient Bill of Rights, Advanced Directives, and Patient Abuse (protection). Serves as a resource for patients, families, and other staff when ethical issues arise. Abides by and carefully adheres to Medical Center Policies for Ethics and Compliance. Demonstrates leadership in safe work practices. (i.e. attention to safety standards, proper body mechanics, proper hand hygiene and nursing bag technique, use of personal protective and safety equipment). Adheres to all safety and health standards, regulations, and work practices and uses personal protective equipment as required. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday-Friday; 7:00 am - 3:30 pm or 8:00 am - 4:30 pm. Subject to change based on needs of the facility. Telework: available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: not authorized Permanent Change of Station (PCS): not authorized
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