Registered Nurse (Home Telehealth Care Coordinator)
Home Telehealth (HT) is defined as a program into which Veterans are enrolled that applies care and case management principles to coordinate care using health informatics, disease management and technologies such as in-home and mobile monitoring, messaging and/or video technologies. The goal of Home Telehealth is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings, high-risk Veterans which chronic disease or Veterans at risk for placement in long-term care. Care Coordinators are case managers that are specialized, highly-skilled and have specific training and competency in the use of disease management, healthcare informatics and HT technologies with complex Veteran patients. They are involved with the ongoing assessment, monitoring and case management of Veterans in their residential environment (or their environment of choice) and provide the appropriate information to providers and the healthcare system to enable just in time care. Care Coordinators serve as case managers who utilize Home Telehealth technology in their practice of case management. Care Coordinators engage in processes that assess, advocate, plan, implement, coordinate, monitor, and evaluate health care options and services so that they meet the needs of the individual patient. Care Coordinators/Case Managers are in touch with Veterans in between their regular visits, advocating for the Veteran, ensuring the Veteran is receiving the care they need, and providing ongoing education and coaching so Veterans improve their ability to manage their chronic conditions. Responsibilities of Care Coordinators may include:
The Home Telehealth RN will be responsible for the electronic health monitoring of an assigned panel of patients with chronic disease conditions such as Diabetes (DM), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Hypertension (HTN), Behavioral Health (Post Traumatic Stress Disorder (PTSD), Bipolar Disorder, Depression and/or Schizophrenia), and/or any additional Co-Morbidities available through Office of Connected Care's Vendor Disease Management Protocols (DMP). Provide initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. The Care Coordinator, through the treatment plan assesses, identifies, analyzes and prioritizes problems, interventions and appropriate measurable goals (i.e., Simple, Measurable, Achievable, Realistic, Time-oriented/(SMART. The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, HBPC, Mental Health and other specialty care services as appropriate for each Veteran enrolled in the program. Triage and assess all data received from HT patients such as vital signs, reported symptoms and question responses. The Care Coordinator will review all patient responses each work day and contact patients with high risk responses and trends, significant changes in condition or changes in other specific data elements received as clinically appropriate. Identify and intervene for potential exacerbations or complications to facilitate timely care in clinic, ER/urgent care, or care in the community. Triage incoming calls and concerns of patients/families, resolve those within scope of practice and route others to interdisciplinary team staff or other services as indicated. Provide face-to-face visits with Linkview (Medtronic) and VVC. Provide interdisciplinary consultation and interventions such as with HBPC and other non-institutional care programs and venues, mental health, social work, pharmacy, nutrition, etc. Identify patients' knowledge, health factors, skills and behaviors that support self-management and identify gaps therein. Provide health care coaching, patient education and psychosocial support. Document and communicate with PACT members regarding changes in status; progress to goals; patterns or trends of data; symptoms or findings of concern and need for provider assessment and/or interventions. Facilitate, document and communicate treatment changes to the Veteran as directed by providers and provide follow up evaluation of the Veteran after changes are implemented. Provide support and guidance and review changes in medications, goals and the treatment plan to Veterans during and after transitions in care such as following a hospital discharge, etc. Assess and analyze outcome indicators, develop action plans for both individual Veteran patients and aggregate populations to enable continuous performance improvement. The Home Telehealth RN must demonstrate exemplary customer service and communication skills. Work Schedule:
Monday through Friday 0700-1600 or 0800-1630 Adhoc Telework may be authorized on a as needed basis. To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/05/2020. Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Graduate of a school of professional nursing approved by the appropriate State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Grade Determinations:
The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience. Preferred
Experience:
2-3 years of Primary Care experience; Triage experience Reference:
VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements:
The physical requirements for this position in accordance with HRML No. 05-12-02 , Employment of People with Disabilities, Including Under Schedule A, 5 CFR 213.3102(u). Heavy Lifting (45 pounds and over); Heavy Carrying (45 pounds and over); Straight pulling and/or Pushing (up to 6-8 hours); Reaching above shoulder; Use of fingers; Both Hands required; Walking (up to 6-8 hours); Standing (up to 4 hours); Sitting (up to 1 hour); Kneeling; Repeated bending (up to 1 hour); Both legs required. Near vision correctable at 13 to 16; Far vision correctable in one eye to 20/20; Hearing (aid permitted); Ability to hear whispered voice. Emotional stability. Ability for rapid mental and muscular coordination simultaneously.
Estimated Salary: $20 to $28 per hour based on qualifications.
The Home Telehealth RN will be responsible for the electronic health monitoring of an assigned panel of patients with chronic disease conditions such as Diabetes (DM), Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Hypertension (HTN), Behavioral Health (Post Traumatic Stress Disorder (PTSD), Bipolar Disorder, Depression and/or Schizophrenia), and/or any additional Co-Morbidities available through Office of Connected Care's Vendor Disease Management Protocols (DMP). Provide initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. The Care Coordinator, through the treatment plan assesses, identifies, analyzes and prioritizes problems, interventions and appropriate measurable goals (i.e., Simple, Measurable, Achievable, Realistic, Time-oriented/(SMART. The treatment plan is an extension of the Veteran's primary care plan and is completed in collaboration with PACT, HBPC, Mental Health and other specialty care services as appropriate for each Veteran enrolled in the program. Triage and assess all data received from HT patients such as vital signs, reported symptoms and question responses. The Care Coordinator will review all patient responses each work day and contact patients with high risk responses and trends, significant changes in condition or changes in other specific data elements received as clinically appropriate. Identify and intervene for potential exacerbations or complications to facilitate timely care in clinic, ER/urgent care, or care in the community. Triage incoming calls and concerns of patients/families, resolve those within scope of practice and route others to interdisciplinary team staff or other services as indicated. Provide face-to-face visits with Linkview (Medtronic) and VVC. Provide interdisciplinary consultation and interventions such as with HBPC and other non-institutional care programs and venues, mental health, social work, pharmacy, nutrition, etc. Identify patients' knowledge, health factors, skills and behaviors that support self-management and identify gaps therein. Provide health care coaching, patient education and psychosocial support. Document and communicate with PACT members regarding changes in status; progress to goals; patterns or trends of data; symptoms or findings of concern and need for provider assessment and/or interventions. Facilitate, document and communicate treatment changes to the Veteran as directed by providers and provide follow up evaluation of the Veteran after changes are implemented. Provide support and guidance and review changes in medications, goals and the treatment plan to Veterans during and after transitions in care such as following a hospital discharge, etc. Assess and analyze outcome indicators, develop action plans for both individual Veteran patients and aggregate populations to enable continuous performance improvement. The Home Telehealth RN must demonstrate exemplary customer service and communication skills. Work Schedule:
Monday through Friday 0700-1600 or 0800-1630 Adhoc Telework may be authorized on a as needed basis. To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/05/2020. Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Graduate of a school of professional nursing approved by the appropriate State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Grade Determinations:
The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience. Preferred
Experience:
2-3 years of Primary Care experience; Triage experience Reference:
VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements:
The physical requirements for this position in accordance with HRML No. 05-12-02 , Employment of People with Disabilities, Including Under Schedule A, 5 CFR 213.3102(u). Heavy Lifting (45 pounds and over); Heavy Carrying (45 pounds and over); Straight pulling and/or Pushing (up to 6-8 hours); Reaching above shoulder; Use of fingers; Both Hands required; Walking (up to 6-8 hours); Standing (up to 4 hours); Sitting (up to 1 hour); Kneeling; Repeated bending (up to 1 hour); Both legs required. Near vision correctable at 13 to 16; Far vision correctable in one eye to 20/20; Hearing (aid permitted); Ability to hear whispered voice. Emotional stability. Ability for rapid mental and muscular coordination simultaneously.
- Department:
0610 Nurse - Salary Range:
$52,098 to $97,291 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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