Registered Nurse - Home Based Primary Care (HBPC)

Summary

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.

Duties

• 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…

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13108967. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equiv…