The RN Home Telehealth Care Coordinator directs care for a panel of patients throughout the continuum of care to ensure that care is timely, appropriate, high quality, and cost-effective. An RPM HT RN Care Coordinator works closely with program staff, the primary care provider (or providers), other healthcare professionals and team members, other clinics, internal or external services and community agencies, and medical center leadership.

Duties

Practice under the National, VISN 19, and VHASLC local guidelines supported by the Remote Patient Monitoring- Home Telehealth Manual, HT Documentation Clinical User Guide, and the OCC Telehealth Manual. Interface with a panel of rural or highly rural Veteran patients via computer to monitor daily responses from Veterans' home monitoring input devices. Provide initial and ongoing comprehensive assessment, including a review of systems that establish a comprehensive plan of care. Identify, analyze, and prioritize problems and interventions and sets appropriate measurable goals (i.e., Specific, Measurable, Attainable, Realistic, and Timely [SMART] goals). The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, HBPC, mental health care, and other specialty care services, as appropriate for each Veteran enrolled in the program. Triage and assessing all data received from RPM - HT patients, such as vital signs, reported symptoms, and question responses. Review daily responses each workday and contact Veterans about worrisome responses and trends, significant changes in condition, or changes in other specific data elements received, as clinically appropriate. Ideally, Care Coordinators should contact Veterans when responses indicate that an issue may be developing - in order to provide education, offer self-management tips, and assist with problem solving rather than waiting until a red alert signal that the situation may be out of control. Identify and intervening to address potential exacerbations or complications in order to facilitate timely care in a clinic, emergency response urgent care setting, or care in the community. Provide appropriate interventions, such as medication management, case management, and patient education. Complete protocol-based interventions as needed. Triage incoming calls and concerns of Veterans or families, resolving those within their scope of practice, and routing others to interdisciplinary team staff or other services, as indicated. Provide interdisciplinary consultation and interventions, such as with HBPC and other non institutional care programs and venues, mental health, social work, pharmacy, nutrition, etc. Identify patient knowledge, health factors, skills, and behaviors that support self-management and identify gaps. Provide health coaching, patient education, and psychosocial support. Document and communicating with PACT or specialty care service members about changes in status, progress toward goals, patterns or trends in data, symptoms, or findings of concern, and need for provider assessment or intervention. Facilitate, documenting, and communicating treatment changes to the Veteran, as directed by providers, and providing a follow-up evaluation of the Veteran after changes are implemented. Provide support and guidance and reviewing changes in medications, goals, and the treatment plan with Veterans during and after transitions in care, such as after a hospital discharge. Assess and analyzing outcome indicators and developing action plans for both individual Veterans and aggregate populations to enable continuous performance improvement. Participate in peer review of documentation for continuous performance improvement. Plan for discharge/transfer of patients, including completing discharge/transfer notes in CPRS. Monitor recovery process and related medical, physical, and psychological problems and other interventions defined by unit policy. Promote and provide health care teaching to patients, including family members, when feasible and appropriate. Demonstrate ability to manage daily routine patient care and workload operations. Seek to improve work processes continuously and offer suggestions for the improvement of patient care. Proactive in identifying potential crises and responds appropriately in emergency situations. Act as a preceptor/mentor to newer staff and/or students. Be compliant and up to date with local and National trainings such as RQI, Toxic Exposures, etc. 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: 7:00 A.M. to 3:30 P.M. Monday through Friday Telework: Available Virtual: This is not a virtual position. Financial Disclosure Report: Not required

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing. Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Preferred Experience: Care Management Experience, ED, ICU, Mental Health, Triage Experience. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: The incumbent must be able to perform all activities of the position without restriction. This position involves considerable standing, walking, stooping, bending, reaching, lifting and turning. It requires repositioning patients and assisting with transferring patients to wheelchairs/stretchers. Mechanical devices when available are required to be used for heavy or difficult to lift patients. The work may involve pushing or lifting weight in excess of 50 pounds and going up and down flights of stairs. The position requires visual and auditory acuity at a level to provide safe and effective nursing care. The positions requires the nurse to work for periods of time with arms above shoulder level or with the neck in a fully flexed or extended position and the ability to physically control or protect him/herself from physically abusive patients.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address VA SALT LAKE CITY HCS 500 Foothill Drive Salt Lake City, UT 84148 US
• Name: Maria Renlund
• Phone: 303-202-8658
• Email: [email protected]