The C-TraC NCM works with the Transitions of Care (TOC) team and is responsible and accountable for developing and implementing comprehensive patient care for the adult/geriatric patient population assessing, planning, implementing, and evaluating activities and programs. The RN Case Manager: Possesses the knowledge and skills necessary to effectively apply all aspects of the nursing process within a collaborative, interdisciplinary practice setting. Effectively implements health promotion and prevention interventions, manages acute and chronic illness states, assists veterans with specialty care (medicine and surgery), assist veterans in the attainment of optimal levels of functioning through rehabilitation and provides supportive measures for the dying patient and their significant others. Is responsible for identifying patients that meet criteria for participation in the TOC programs. Collaborates with other members of the TOC team to determine which program best fits the patient's needs. Participates in daily hospital multidisciplinary discharge rounds. Utilizes the nursing process in managing, developing, implementing, and evaluating each patient's individual plan in collaboration with the interdisciplinary care team to attain specific clinical outcomes. Provides individualized inpatient transitional care teaching to patients prior to discharge from the acute hospital setting. Arranges an initial telephone visit with the patient 1-3 days after hospital discharge and is responsible for scheduling follow up phone calls at least weekly for up to four weeks following hospital discharge. Reviews the four pillars of transitional care: 1)Red flags-signs/symptoms that they should seek medical attention 2) Who to call 3) Medication reconciliation, patient led, including all OTC's and supplements, and 4) Future clinical follow up including clinic visits, labs, diagnostic testing, and outstanding consults during telephone consultation. Follow up with patients, monitoring and ensuring adherence to treatment plans, intervening in accordance with prescribed guidelines. Reports to primary provider on all cases. Arranges for additional community services, supplies, or consults as appropriate. Collaborates with primary care, specialty services, or hospitalist team to resolve medication discrepancies, clarify activity restrictions, diet orders, follow up plans, or other issues that have arose since hospital discharge. Provides for the educational needs of the health care team regarding Transitional Care. Maintains and upgrades own knowledge base and skills regarding Case Management and Transitional Care and applies this knowledge to nursing practice. Participates in clinical research/EBP within transitional care or related to case management. Serves as a resource for other team members and participates in planning for program improvements at the local level. Work Schedule: Monday-Friday 8AM-4:30PM Telework: n/a Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.
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