Registered Nurse - Home Based Primary Care; HBPC)

• Department: Department of Veterans Affairs

Home Based Primary Care (HBPC) Outpatient Staff Registered Nurse (RN) is responsible for providing competent, evidence-based care to HBPC patients and oversight of licensed vocational nurses/nursing assistants, as appropriate to the setting. This nurse provides direct Veteran care and care coordination, as it pertains, to Veterans and their care within the HBPC Program.

Registered Nurse
- Home Based Primary Care (HBPC) duties include but are not limited to:
Developing and coordinating the patient's plan of care to include ongoing assessment and reassessment, care planning, care coordination, monitoring, and evaluating clinical outcomes.

- Interacting, coordinating, and advocating for the patient/caregiver with other relevant parties across a continuum of care, beyond a single episode of care, ensuring seamless transitions.

- Providing individualized education and support to the patient and caregiver to optimize clinical outcomes and support quality of life decisions.

- Delegating and supervising the care given to the patient by licensed practical nurses, and home health technicians, as applicable.

- Providing intensive care management for assigned patients.

- Linking Veterans with resources.

- Coordinating resources for comprehensive care to avoid duplication of services and streamline staff interaction and services with the Veteran.

- Conducts assessments in the home to develop treatment goals and plans based on comprehensive interdisciplinary assessment of the patient and the caregiver.

- Participates in the development of the individual plan of care at interdisciplinary care meetings for assigned panel of patients.

- Implements the plan of care through home visits or Telehealth, as indicated.

- Reviews progress toward goals at regular intervals, as a team, on a quarterly basis, or more frequently when there is a change in the patient's condition.

- Assess and support the caregiver's capability to continue to provide care.

- Assesses clinical data for neurological, cardiac/vascular, respiratory, gastrointestinal, genitourinary, and skin and documents findings and reports abnormalities.

- Incorporates assessment findings into treatment plan.

- Coordinates care with other health care providers in assessing, planning, implementing, and evaluating treatment interventions.

- Coordinates transitions of care from outpatient to inpatient or emergency department settings through communication with outpatient facilities and the interdisciplinary team.

- Appropriate documentation as established by HBPC Standard Operating Procedures (SOP).

- Administers medication safely and accurately.

- Identifies patients at high risk for harm to self and follows established SOPs on Suicide Risk.

- Establishes and maintains effective communication with patients, family members, and the interdisciplinary team.

- Assumes responsibility for telecare calls that can be handled by the RN, directing to the physicians those calls that must have physician response.

- Serves as liaison with physician and patient and discusses concerns with the physician and calls the patient back. Establishes a rapport with patients to encourage them to call when a healthcare problem arises.

- Performs venipuncture in the home per competency and reviews lab and test reports and alerts the physician of significant findings and assists the physician with appropriate follow up and treatment.

- Identifies learning needs of the patient/family (diagnosis, medication, surgery, etc.) and implements teaching strategies or provides alternate methods of communication (e.g. dry erase boards, picture charts, etc.) to patients with learning difficulties.

- Understands the legal ethical implications of Patient Self Determination Act, Patient Bill of Rights, Advanced Directives, and Patient Abuse (protection).

Serves as a resource for patients, families, and other staff when ethical issues arise. Abides by and carefully adheres to Medical Center Policies for Ethics and Compliance. Driving is required for this position.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay:
Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement:
Traditional federal pension (5 years vesting) and federal 401K with up to 5% in…