The PACT Nurse Care Manager (NCM) is assigned to Fairview CBOC, Primary Care Division, VA Portland Healthcare System. The NCM demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients at VAPORHCS The NCM demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for an assigned panel of patients at VAPORHCS: Recognizing the age-related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient focusing on chronic disease management. Identifies and provides 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). Utilizes other registries to manage disease processes such as Diabetic, Mammography, Cardiovascular, and Opioid Registries to access data base for pain management. Performs 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. Utilizes Teach and Motivational Interviewing techniques to encourage positive health behavioral change and Health Promotion and Disease Prevention. Provides patient and family education with a focus on self-management, prevention, and wellness, based on 'what matters most' to the patient. 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. Facilitates continuity of care by partnering with multidisciplinary services, internal and external to the Department of Veterans Affairs. Initiates and participates in various quality and process improvement activities that result in improved patient outcomes. 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. Utilizes facility approved Nursing Protocols and Guidelines to enhance patient care as appropriate. Collaborates with PACT and Expanded PACT to participate/provide shared medical appointments/ group clinics for patients with specific chronic disease diagnoses. 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. Provide VA Video Connect (VVC), Clinical Video Technology (CVT), or Telemedicine. The NCM is responsible for maintaining knowledge of and skill in applying an intensive body of rules, procedures, and operations in telehealth related technologies and a variety of computer hardware/ software used in technology, data entry, retrieval, record maintenance, document, and report generation. Including 1) preparing the clinical environment, which may include telecommunications equipment to be used for clinical examination and treatment 2) serve, within their of scope of practice, as a tele presenter for VVC or Telemedicine in task such as establishing and maintaining video connection, making introductions between patients and providers and following the instructions of the clinician to facilitate an effective clinical encounter; 3) taking measures to ensure patient care is delivered safely by following appropriate procedures for cleaning of clinical equipment and care of environment by following all safety guidelines, protocols, and procedures: 4) completing standardized clinical questionnaires and templates within scope of training and applicable guidelines; 5) arranging and completing test video calls with veterans in preparation of video calls; 6) ensuring information and resources are maintained for local and remote telehealth providers so they can effectively execute contingency and emergency plans. Work Schedule: Monday- Friday, varying hours, 07:00 am - 5:30 pm Telework: Not available Virtual: This is not a virtual position. 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.