About the position The Registered Nurse Remote Patient Monitoring- Home Telehealth Care Coordinators are case managers and health coaches who are highly skilled and have specific training and competency in the use of disease management, health care informatics, and remote patient monitoring technologies. Case management is the cornerstone of Remote Patient Monitoring -Home Telehealth (RPM-HT). Thorough, regular chart reviews and daily monitoring of data are only part of the overall management of care.

Responsibilities

• Practices under the National, VISN 19, and VHASLC local guidelines supported by the Remote Patient Monitoring- Home Telehealth Manual, HT Documentation Clinical User Guide, and the OCC Telehealth Manual.
• Interfaces with a panel of rural or highly rural Veteran patients via computer to monitor daily responses from Veterans' home monitoring input devices.
• Provides initial and ongoing comprehensive assessment, including a review of systems that establish a comprehensive plan of care. T
• Identifies, analyzes, and prioritizes problems and interventions and sets appropriate measurable goals (i.e., Specific, Measurable, Attainable, Realistic, and Timely goals). The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, HBPC, mental health care, and other specialty care services, as appropriate for each Veteran enrolled in the program.
• Triages and assesses all data received from RPM - HT patients, such as vital signs, reported symptoms, and question responses.
• Reviews daily responses each workday and contact Veterans about worrisome responses and trends, significant changes in condition, or changes in other specific data elements received, as clinically appropriate.
• Contacts Veterans when responses indicate that an issue may be developing - in order to provide education, offer self-management tips, and assist with problem-solving - rather than waiting until a red alert signals that the situation may be out of control.
• Completes an assessment of patients who may have multiple and complex comorbidities that necessitate additional coordination of care and case management to ensure easily accessible, continuous, high-quality care across all settings.
• Provides ongoing professional assessment and case management to an adult population of predominantly (but not limited to) older male patients.
• Completes assessment and plan of care on assigned patients and provides individualized nursing care.
• Conducts ongoing reassessments to evaluate changes in patients' status.
• Identifies and intervenes to address potential exacerbations or complications in order to facilitate timely care in a clinic, emergency response urgent care setting, or care in the community.
• Provides appropriate interventions, such as medication management, case management, and patient education. Completing protocol-based interventions as needed.
• Triages incoming calls and concerns of Veterans or families, resolving those within their scope of practice, and routing others to interdisciplinary team staff or other services, as indicated.
• Provides interdisciplinary consultation and interventions, such as with Home Based Primary Care (HBPC) and others on institutional care programs and venues, mental health, social work, pharmacy, nutrition, etc.
• Identifies patient knowledge, health factors, skills, and behaviors that support self management and identifying gaps.
• Provides health coaching, patient education, and psychosocial support.
• Provides support and guidance and reviewing changes in medications, goals, and the treatment plan with Veterans during and after transitions in care, such as after a hospital discharge.
• Plans for discharge/transfer of patients, including completing discharge/transfer notes in CPRS.
• Monitors recovery process and related medical, physical, and psychological problems and other interventions defined by unit policy.
• Seeks to improve work processes continuously and offer suggestions for the improvement of patient care.
• Acts as a preceptor/mentor to newer staff and/or students.

Requirements

• Licensure: 1 full and unrestricted license from any US State or territory Benefits
• 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 contributions by VA
• Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)