Advanced Practice Nurse - Community Living Center and Home-Based Memory Care

Summary

VA Black Hills Health Care System (VA BHHCS) is seeking an Advanced Practice Nurse (APN) Nurse Practitioner (NP) to care for Veterans at the BHHCS Community Living Center (CLC) with the expectation to expand services to Veterans with neurocognitive disorders, focusing on dementia care in the CLC and as a provider of a Home‑Based Memory Care (HBMC) team. This vacancy is posted as an Advanced Practice Nurse and Physician Assistant for one position.

• The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers
• This is an approach to healthcare that empowers and equips people to take charge of their health and well‑being and live their lives to the fullest
• As an employee operating in a Whole Health System of care – you will operate in a model with three core elements – seeking to create a personalized health plan for each Veteran
• This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community
• This aligns with the Veterans Health Administration (VHA) Mission Statement to honor America's Veterans by providing exceptional health care that improves their health and well‑being
• The APN practices in Rehab and Extended Care Services to provide a full range of services emphasizing quality, timeliness, and the advancement of the Veterans Affairs (VA) mission
• The NP provides advanced clinical practice, consultation, and management
• Duties include – but are not limited to:
  Obtains medical histories and performs physical examinations at admission to CLC or Home‑Based Primary Care (HBPC) team and annually
• Documents discharge notes and summaries at the time of discharge
• Provides and coordinates medical care for assigned patients – including establishing diagnoses, formulating, and implementing care plans, and providing follow‑up care
• Orders and interprets diagnostic testing results and therapeutic modalities – including, but not limited to, laboratory tests, ECG, radiological studies, oxygen, etc. – based on the current CLC treatment guidelines for stable patients
• Orders ancillary services – including, but not limited to, pharmacy, social services, physical medicine and rehabilitation therapies, prosthetic services, etc.
• Attends CLC Interdisciplinary Team to coordinate care for CLC Veterans
• Orders VA specialty service consults and initiates requests for non‑VA medical care and consults in accordance with VHA and local facility policy and procedures
• Orders interfacility transfers and other transportation for CLC Veterans
• Orders or prescribes devices, supplies, and durable medical equipment
• Orders or prescribes medications for patients under their care
• Conducts Goals of Care conversations with high‑risk patients regarding any desired limitation in life‑sustaining treatments and choice of surrogate, and enters the Life‑Sustaining Treatment Decisions (LST) progress note and corresponding orders when a Veteran is under their care or if delegated by the attending physician
• Telehealth modalities may be utilized for the provision of care by an authorized provider pursuant to service level guidance – required training and instruction – and in collaboration with the Facility Telehealth Coordinator (FTC)
• Provides clinical oversight and participates in peer review of other Rehabilitation and Extended Care providers through periodic chart reviews
• Acts as a surrogate for absent CLC providers as needed – to include review of EMR view alerts and other duties as assigned
• Regularly attends all provider meetings – departmental meetings and medical staff meetings as requested
• Conducts home visits to assess needs of patients and their caregivers enrolled in home‑based primary care and the home‑based memory care team
• Performs comprehensive medical assessments and evaluations in the patients' home setting with consultation with Medical Director – as needed
• Performs medication reconciliation in home setting
• Manages and treats medical conditions in the home setting – involving Medical Director as needed
• Formulates multidisciplinary treatment plans
• Provides health education to patients and their caregivers
• Responds to telephone calls from…