The incumbent is assigned to unit or section of Associate Chief of Nursing in Ambulatory Care. The unit or section description and patient population served is as defined in applicable Scope of Service. The incumbent practices in a patient care setting with general supervision as needed for direction. The incumbent is accountable as assigned as a Care Coordinator for a defined group of patients on his/her shift.

Duties

HOME TELEHEALTH CARE COORDINATOR ESSENTIAL FUNCTIONS: Work in the Home Telehealth setting with other Home Telehealth RN Staff. This RN will work closely with referring providers in the Patient Aligned Care Team, Home Based Primary Care (HPBC) and Out-Patient Clinics, as well as with Specialty clinic referring parties. This RN will provide Care Coordination and Care Management using Home Telehealth technology using the Disease Management Protocols. Provide initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. The Care Coordinator through the treatment plan assesses, identifies, analyzes, and prioritizes problems, interventions and appropriate measurables goals (i.e., Simple Measurable, Achievable, Realistic, Time-oriented (SMART) goals). The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, CBOC, HBPC, Mental Health, and other specialty care services as appropriate for each Veteran enrolled in the program. S/he Supports and provides Coordination with Home Telehealth Lead and other Care Coordinator RN to assure: Triage and assessment of all data received from Home Telehealth patients such as vital signs, reported symptoms, and question responses. Contact patients with high-risk responses, significant changes in condition or changes in other specific data elements received. Identify and intervene for potential exacerbations or complications to facilitate: Just in Time care in clinic, ER/urgent care, or care in the community. Provider-directed interventions such as medication management. Protocol-based interventions. Triage calls and concerns of patient/family and resolve those within scope of practice and route others to primary care staff or other services as indicated. Provide opportunity for extension of length of time between routine primary care and/or HBPC encounters for stable patients. Provide communication and data exchange with community-based providers when there is comanaged care. Provide psychosocial support to patients. 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 patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Provide health care coaching, patient education, and motivational counseling. Document and communicate with provider regarding progress to goals; patterns or trends of data, symptoms, or findings; concerning findings; need for provider assessment and/or interventions. Facilitate, document, and communicate treatment changes directed by the provider and provide follow up evaluation of the patient after the changes are implemented. This RN is required to obtain additional competency in Telehealth/Home Telehealth supported by online, TEAMS based and face to face training. Demonstrates grade-appropriate and consistent critical thinking skills: The nurse can recognize the patient has a problem. The nurse can manage the problem safely and effectively, recognizing his/her scope of practice. The nurse has a relative sense of urgency. The nurse takes the right action for the right reason (del Bueno). Provides age-specific care for adult (18-64) and geriatric (65 and older) patients/residents/groups including the following elements: promotes independence; encourages self-care; involves family or designated caregiver with care planning, provides necessary safety measures and access to privacy; assists patient/resident to cope with changes affecting mobility, balance, cognition, psychosocial function, and physical/sensory changes. Role-specific Competency Checklist is complete and is rated competent in all measured areas. Answer view alerts/secure messages within 24-48 hours Perform reminders as appropriate (influenza, audit-c, depression, PTSD, etc.). Perform daily huddle with the Home Telehealth team. Promote non-face to face visit support (MHV/secure messaging, telephone access/ appointments, VVC) RN to cover duties of Home Telehealth Care Coordinator upon absence: Manage panel. Patients follow up and interventions with actions. Patient Care Coordination (e.g., follow-up with patient for continuity of care purposes/assessment, coordinating with external departments for care benefit of the Home Telehealth patient). Performs duties as assigned. Work Schedule: Mon-Fri 7:30 AM- 4:00 PM Financial Disclosure Report: Not required

Requirements

Qualifications

Preferred Experience: 1 year current Outpatient Care Coordination/Care Manager, or 1 year current Discharge planner 1 year current Lifestyle coaching with chronic disease management Survey Readiness experience1 year current virtual (VVC) Telehealth modality Certified Case Manager , or Certified Life Coach Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), 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 the appropriate accrediting agency and accredited 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). 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. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12363788. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. 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: Heavy lifting (45 lbs. and over); Moderate Carrying (15-44 pounds); Straight Pulling; Pushing; Reaching above Shoulder; Walking; Standing; Repeated bending; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Hearing aid (permitted); Ability to distinguish basic colors; Ability to distinguish shades of colors; Depth perception; Both eyes required; Both legs required; Use of fingers and both hands required. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at http://www.opm.gov/qualifications

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Jerry L Pettis Memorial Veterans Hospital 11201 Benton Street Loma Linda, CA 92357 US
• Name: Robin Sandoval
• Phone: (909) 583-6138
• Email: [email protected]