The Hospital in Home, HIH RN is a professional registered nurse who collaborates with medical, nursing, ancillary and technical staff to deliver high quality, individualized and cost-effective patient care. The RN functions as a case manager coordinating the patient care with interdisciplinary team members, 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. The RN will assess the status of admitted patients via home visits, telehealth visits, and telephone visits and develops and coordinates the patient's plan of care to include ongoing assessment and re-assessment, care planning, care coordination, monitoring, and evaluating clinical outcomes. The RN provides individualized education and support to the patient and caregiver to optimize clinical outcomes and support quality of life decisions. Additional duties include but are not limited to: * Post-acute care case management & in-home physical assessments, inclusive of, but not limited to the following: medication management, point of care testing, phlebotomy, wound care and catheter care in the home per established policies, protocols, and guidelines. * Interacts with Veterans and their family/caregivers by telephone or in person to facilitate treatment plan. * Utilizes the nursing process, as appropriate, to set priorities, plan, organize, and implement care that is directed toward a positive patient outcome within a dynamic environment. Work Schedule: Monday - Friday 0730 to 1600 Telework: Not Authorized Virtual: This is not a virtual position. Travel: Travel is required >75% of the time. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.