The Registered Nurse (RN) assigned to the VAPORHCS Patient Aligned Care Team (PACT) Primary Care Clinic functions as the PACT Nurse Care Manager (NCM) and may be assigned to the clinics located in Portland, Vancouver, Camp Rilea, Bend, Salem, Fairview, The Dalles, West Linn, Community Resource Referral Center (CRRC), or Hillsboro. Duties include but are not limited to: Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients Recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient focusing on chronic disease management. Identifies and provides case management for high-risk cohort of patients utilizing chronic disease management data mining tools to include but not limited to Care Management Tool (CMT), Business Intelligent Strategic Learning (BISL), VISN 20 Access Report, VISTA, and VHA Support Service Center (VSSC) reports such as PC Almanac, Compass, Primary Care Management Module (PCMM) Care Needs Assessment (CNA).Utilizes other registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management. Performs timely Post-Discharge/ ED/ Urgent Care and Walk-ins' using appropriate documentation templates/notes, codes, education. Assesses and enrolls eligible patients into nontraditional modalities of care such as Home telehealth and Telemedicine. Utilizes Teach and Motivational Interviewing techniques to encourage positive health behavioral change and Health Promotion and Disease Prevention. Provides patient and family education with a focus on self-management, prevention, and wellness, based on 'what matters most' to the patient. Reviews, tracks, and devises strategies to improve Healthcare Effective Data Information Sets (HEDIS) metrics, clinical reminders, panel access, timely encounter closures, and other performance metrics. Facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs. Initiates and participates in various quality and process improvement activities that result in improved patient outcomes. Enhances clinic access and team performance by pre-planning/ pre-appointment chart review daily huddles and weekly meetings with PACT teamlet and other members of the extended PACT. Utilizes facility approved Nursing Protocols and Guidelines to enhance patient care as appropriate. Collaborates with PACT and Expanded PACT to participate/provide shared medical appointments/ group clinics for patients with specific chronic disease diagnoses. Demonstrates leadership by serving as an advocate for patients and a team leader with colleagues as he/she continues to enhance his/her own professional growth, continuing education and development. Provide VA Video Connect (VVC), Clinical Video Technology (CVT), or Telemedicine. May be required to perform specimen collection of (urine, sputum, blood, or stool) ensuring to utilize proper labeling, packaging, and transport instructions from the Primary Care Community Based Clinics or assigned areas to the main facility laboratory. Utilize proper facility required patient identified methods and ensure patient confidentiality is maintained. Access and complete specimen orders from the hospital computerized system, utilize centrifugation (id required), and prepare specimen prior to laboratory testing. Incumbent will exercise effective communication skills prior to, during, and after specimen collection, ensuring to review pertinent information with the patient. Maintain specimen integrity by using aseptic techniques, following department procedures, and observing and adhering to personal protective equipment policies and guidelines. Work Schedule: Monday-Friday, varying tours from 0700-1730 Telework: Not available Virtual: This is not a virtual position. 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.