Administratively responsible to the Home Based Primary Care Program Director with clinical accountability for nursing practice to the Associate Director Patient Care Services/Nurse Executive (APDCS/NE). The incumbent is assigned to the Home Based Primary Care (HBPC) program. HBPC is a component of the Eugene Community Based Outpatient Clinic Ambulatory Care service line. HPBC provides comprehensive, physician supervised interdisciplinary primary care administered to veterans in their homes. The HBPC nurse will be the primary coordinator of services, managing patients with multiple complex medical or mental health problems requiring prolonged intervention to maintain or improve status and retard decline.
In addition, the HBPC nurse may also consult in clinical areas in which they are considered experts or specialists. Examples may include but are not limited to wound care, diabetes management or ostomy management.
The incumbent has responsibility as a Nurse Care Manager for a panel of primary care patients in collaboration with a Patient Aligned Care Team (PACT) and maintains an independent panel of Home Telehealth (HT) patients under the direction of the Manager of the Home Telehealth program. Responsible and accountable for all elements of the nursing process when providing direct or virtual care. The nurse assesses, plans, implements, and evaluates care based on age- and culture-specific components. The nurse provides care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process, which includes systematic data gathering, assessment, appropriate nursing judgment, and evaluation of human responses to actual or potential health problems through such services as case finding, health teaching, health counseling; provision of care supportive to or restorative of life and well-being; and executing medical regimens including administering medications and treatments prescribed by a licensed or otherwise legally authorized provider.
The incumbent provides and/or directs the coordination of care, telephone triage and planning of multiple health care services; acts on behalf of the veteran to assure that necessary clinical services are received and that progress is being made. The incumbent is responsible to facilitate communication and collaboration between all members of the healthcare team (PACT) involving the patient and family in the decision-making process; to minimize fragmentation of healthcare delivery; to optimize quality of patient and family outcomes in a cost-effective manner. He/she provides professional assessment, coordination and planning of multiple health care services; acts on behalf of the veteran to assure that necessary clinical services are received and that progress is being made. Provides on-going case management services. Care will be provided in the least restrictive, most cost-effective manner through use of the clinical practice guidelines and clinical pathways. Evidence of health promotion and chronic disease indices will be monitored through the clinical practice guidelines and performance measures. Uses equipment correctly and accurately interprets data, particularly Home Telehealth monitoring, video teleconferencing (v-tel), and secure messaging. Collaborates with patients, families, health care practitioners, and health care leaders in policy and program development, implementation, and evaluation, and in the delivery of care (Patient and Family Centered Care).
Work Schedule: Monday - Friday (8:00am - 4:30pm)
Note: This position will require provider visits to HBPC patients in their
homes so individual selected must have and maintain a valid driver's
license. A GSA vehicle will be used, if available; otherwise access to a
personal vehicle will be required to travel to patient homes.
Reimbursement of mileage at government approved rates will be approved if
personal vehicle is used.
Position Description (Title/PD): Registered Nurse (HBPC) / Functional Statement
Relocation/Recruitment Incentive: Incentives will not be authorized for this position.