Registered Nurse, Ambulatory Care - Patient Aligned Care Team (PACT)
Veterans Affairs, Veterans Health Administration
Location: Capitola, California
Internal Number: 626277800
This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application. Learn more This is an Open Continuous Announcement that will be used to fill open vacancies throughout the VA Palo Alto Health Care System and will remain open until 10/18/2022. Applications will be accepted on an ongoing basis and qualified candidates will be considered and referred as vacancies become available. The Registered Nurse uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Provider, Nursing, and Support Personnel) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. The Registered Nurse is a member of the core clinical team of ambulatory care. The RN is responsible for collaborating with services internal and external to the VA to facilitate care transition to effectively meet the patients' needs. The RN provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RN demonstrates leadership by serving as an advocate for patients, team player to colleagues as she/he continues to enhance the own team's professional growth, development, and practice. Duties include but are not limited to: * Demonstrates advanced clinical knowledge in assessing planning, implementing, documenting, and evaluating care for a designated group of patients across the continuum of care: Recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient. * Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. * Collaborates with patients to assess and identify needs, issues, care goals, and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness. * Maintains current knowledge of multidisciplinary resources, programs and services, referring patients for community resources as appropriate. * Demonstrates ability to collaborate with all levels of services and disciplines. Collaborates with patient, family and care providers in all settings where care is being provided to evaluate and update changes in the patient-driven life plan and patient management. * Reviews options with patients and families, including costs, alternatives, risks/benefits and services. * Assists with the navigation of health care systems and intervenes or refers as needed to facilitate the achievement of patient outcomes. * Enhances patient self-management by providing information regarding all options, choices, and resources. * Provides care, respecting patient's personal values, cultural, and belief system. * Actively participates in care delivery with priority attention to patient preference. * Maintains confidentiality of all patient information, including electronic, print, and conversations. * Provides and promotes patient-driven care in a safe, efficient and cost-effective manner, using evidence-based principles. * Promotes cost effective use of resources; effective least-expensive strategies expected in non-face-to- face approaches (including telehealth) * Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes. * Applies skills, such as motivational interviewing to promote patient self-management toward patient-driven holistic care plan for life. * Supports the facility's EEO/affirmative action programs by executing assigned duties and responsibilities in a professional manner. * Provides age and population specific care and education. * Guides others in the recognition of and participates in the resolution of ethical issues. * Promotes health promotion and risk reduction strategies. * Works with interdisciplinary teams on care coordination, disease prevention and population health management. * All work assigned by Nurse manager and/or service Chief/Assistant Chief of ACC. Work Schedule: Monday - Friday 8:00 am to 4:30 pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Authorized EDRP Authorized: Contact V21CCOEEDRP@va.gov, the EDRP Coordinator for questions/assistance 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.