The Registered Nurse Care Manager in the Ambulatory Care Service uses the nursing process and evidence-based practice to collaborate with the Teamlet (Patient, Primary Care Provider, RN Care Manager, Clinical Associate and Clerical Associate) and expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven care plan for life. The RN Care Manager is a member of the Teamlet team. The RN Care Manager is responsible for collaborating with services internal and external to the VA to facilitate care transition in order to effectively meet the patients' needs. The RN Care Manager provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals.
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