The Transition Team is a multidisciplinary team that addresses the healthcare needs of Veterans receiving Inpatient Care, Outpatient Primary and Specialty Care, and Extended Care Services. The incumbent's primary functions are nursing case management and coordination of patient care. The incumbent provides nursing support to inpatient medicine and specialty teams, including assisting with discharges from outside hospitals. The incumbent provides nursing support to PACT teams, specialty clinics, and community-based outpatient clinics. Patients that require Transition Nurse intervention include, but are not limited to, nursing home patients, patients requiring home health/hospice services, and high-risk patients. High risk patients include those with frequent inpatient admissions, chronic illnesses, limited support, multiple health concerns, numerous medications, medication treatments requiring follow-up, advanced age, cognitive deficits, acute episodes requiring post-hospital monitoring, and medical non-compliance. The incumbent provides nursing case management that compensates for and assists in meeting the health-related self-care deficits of the Veteran patient, supports and leads in the provision of appropriate care for Veterans ranging from 18 through the geriatric years, and takes into consideration diagnoses and physical, psychosocial, spiritual and cultural needs. Work Schedule: Part Time, Every Saturday and Sunday 7am to 530pm Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.