U.S. Department of Veterans AffairsRegistered Nurse Care Manager
Jan. 2022Spokane, Washington, United States- Ongoing, continuous care of one or more assigned panel(s) of Veterans
- Utilizes all available tools, such as registries, to enable effective and efficient identification and intervention of individual patients and cohorts
- Ensures appropriate evaluation and access is provided to patients assigned to the patient panel
- Functions at the full extent of the team member's relevant clinical privileges, credentials, scopes of practice, elements of practice, certification, functional statement, position description, or other VHA or local facility approved documentation of competency
- Participates in team performance improvement and sustainment activities to optimize team efficiency and care delivery of patients
- Implements primary care operations management processes, as appropriate
- Manages communications and facilitates safe transitions of patients between the PACTs site of care and other health care settings, using informal and formal communication methods, as appropriate
- Provides health education and health coaching on wellness, disease prevention, chronic care management, and self-management skills to patients and personal support persons, commensurate with the documented expertise or professional training of the PACT member
- Collaborates with informatics technology staff to develop and implement systematized, electronically supported, standardized tools to support PACT care delivery processes