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    The RN functions as a Case Manager for the HBPC assigned veterans, and is responsible for:
    Assessing and continually reassessing the needs of veterans and caregivers.
    Delivering nursing care in the home.
    Delegating and supervising the care by LPNs or vocational nurses, and home health technicians, if applicable.
    (VHA Handbook 1141.01 HBPC, 2007)

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    • Demonstrated clinical competencies in such areas as age-specific care, cultural assessment, and health education.
    • An ability to effectively function autonomously, as well as a member of an interdisciplinary team
    • Respect for cultural and spiritual values.
    • A commitment to discipline-specific standards of practice, including: ethical conduct, the primary care delivery model, chronic disease management, palliative care, principles of care management, a holistic framework of practice, and geriatric care skills (including infection control, equipment and environmental safety).
    • Determine the appropriateness of patients for admission into the HBPC Program.
    • Help develop patient treatment plans based on a comprehensive interdisciplinary assessment of the patient and the caregiver.
    • Implement the patient's treatment plan through home visits, as needed.
    • Review the patient's progress as a team at regular intervals, at least every 90 days, or when there is a change in the patient's condition.
    • Assess and support the caregiver's capability to continue to provide care.
    • Educate the patient and the caregiver.
    • Coordinate the process of care with the other team members to maximize efficiency.
    • Assess the patient's continuing need for HBPC care, and plan for HBPC discharge when indicated.
    • Document all patient care activities in a timely manner (per facility policy).
    • Identify areas for continuing education and participate in in-service training (including staying current with all required education).
    • Participate in developing and implementing the performance improvement plan (including quality monitors).
    • Instruct students of various disciplines in the challenges encountered in delivering health care in the home setting.
    • Serve as a role model in the effective operation of an interdisciplinary team.
    • Participate in the development and periodic review of the local HBPC Policy and Procedure Manual.
    • Utilize VHA and community resources as appropriate.
    • Participate in HBPC team meetings.
    • Case management of 20-30 patients.
    • (VHA Handbook 1141.01 HBPC, 2007)

    Work Schedule: Mon- Friday 08-1630
    Financial Disclosure Report: Not required

    Travel Required

    75% or less - You will be expected to travel for this position.

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/532396500. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.