The Registered Nurse (RN) assigned to the VAPORHCS Patient Aligned Care Team (PACT) Primary Care Clinic functions as the PACT Nurse Care Manager (NCM) and assigned to the Salem, Oregon clinic. The PACT(Patient Aligned Care Team) NCM (Nurse Care Manager) is a member of the PACT Teamlet (Primary Care Provider, Nurse Care Manager, Licensed Practical Nurse, Health Technician, and Clerical Associate) and supports the work of the expanded team (Pharmacist, Social Worker, Home Telehealth RN, Psychologist, and Dietician). The NCM demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients at VAPORHCS. The NCM is responsible for: 1) recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient focusing on chronic disease management; 2) identifying and providing case management for high-risk cohort of patients utilizing chronic disease management data mining tools to include but not limited to Care Management Tool (CMT), Business Intelligent Strategic Learning (BISL), VISN 20 Access Report, VISTA, and VHA Support Service Center (VSSC) reports such as PC Almanac, Compass, Primary Care Management Module (PCMM) Care Needs Assessment (CNA); 3) utilizing other registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management; and 4) performing timely Post-Discharge/ ED/ Urgent Care and Walk-ins using appropriate documentation templates/notes, codes, education. Assesses and enrolls eligible patients into nontraditional modalities of care such as Home telehealth and Telemedicine. The NCM utilizes Teach and Motivational Interviewing techniques to encourage positive health behavioral change and Health Promotion and Disease Prevention. S/he provides patient and family education with a focus on self management, prevention, and wellness, based on 'what matters most' to the patient. The NCM reviews, tracks, and devises strategies to improve Healthcare Effective Data Information Sets (HEDIS) metrics, clinical reminders, panel access, timely encounter closures, and other performance metrics. The incumbent facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs, and initiates and participates in various quality and process improvement activities that result in improved patient outcomes. S/he enhances clinic access and team performance by pre-planning/ pre-appointment chart review daily huddles and weekly meetings with PACT Teamlet and other members of the extended PACT. The NCM utilizes facility approved Nursing Protocols and Guidelines to enhance patient care as appropriate. S/he collaborates with PACT and Expanded PACT to participate/provide shared medical appointments/ group clinics for patients with specific chronic disease diagnoses. The NCM demonstrates leadership by serving as an advocate for patients and a team leader with colleagues as he/she continues to enhance his/her own professional growth, continuing education and development. Work Schedule: Monday through Friday, Varying tours from 7:00am to 5:30pm 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.