Registered Nurse-Remote Patient Monitoring-Home Telehealth (RPM-HT) Program id-6476
About the position
The Connected Care Department in Atlanta, GA is seeking a Registered Nurse for the Remote Patient Monitoring-Home Telehealth (RPM-HT) Program. This position involves providing comprehensive assessments and developing care plans for patients, particularly veterans, who require ongoing monitoring and support. The nurse will collaborate with various healthcare teams, including PACT, HBPC, and mental health services, to ensure that patients receive the necessary care tailored to their individual needs. The role requires triaging and assessing data from RPM-HT patients, including vital signs and reported symptoms, to identify any potential complications or exacerbations in their health status. In addition to conducting assessments, the nurse will provide ongoing care management for an adult population, focusing on older veterans. This includes developing individualized nursing care plans, conducting regular reassessments, and implementing appropriate interventions such as medication management and patient education. The nurse will also be responsible for documenting changes in patient status and communicating effectively with interdisciplinary teams to facilitate timely interventions. The position requires a proactive approach to patient care, including health coaching and advocacy, as well as the ability to manage daily patient care operations efficiently. The nurse will also participate in continuous performance improvement initiatives and may act as a mentor to new staff or nursing students. This role is essential in promoting high-quality care and ensuring that veterans receive the support they need to manage their health effectively.
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Responsibilities
- Provides initial and ongoing comprehensive assessment, including a review of systems that establish a comprehensive plan of care.
- Collaborates with PACT, HBPC, mental health care, and other specialty services as needed.
- Triages and assesses all data received from RPM-HT Program patients, such as vital signs, reported systems, and question responses.
- Completes an assessment of patients who may have multiple and complex comorbidities that necessitate additional coordination of care and case management.
- Provides ongoing professional assessment and care management to an adult population of older (but not limited to) Veterans.
- 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.
- Completes protocol-based interventions as needed.
- Triages incoming calls and concerns of Veterans or families, resolves those within their scope of practice, and routing others to interdisciplinary staff or services, as indicated.
- Provides interdisciplinary consultation and interventions with programs and departments such as 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, psychosocial support and patient advocacy as required.
- Documents and communicates with PACT or specialty care service members about changes in status, progress toward goals, patterns or trends in data, symptoms or finding of concern, and the need for provider assessment or intervention.
- Facilitates, documents, and communicates treatment changes to the Veteran, as directed by providers, and provides a follow-up evaluation of the Veteran after changes are implemented.
- Provides support and guidance and reviews and reviews changes in medications, goals, and the treatment plan with Veterans during and after transitions in care, such as after a hospital discharge.
- Assesses and analyzes outcome indicators and develops action plans for both individuals Veterans and aggregate populations to enable continuous performance improvement.
- Participates in peer review of documentation for continuous performance improvement.
- Plans for discharge/referral of patients to the L2 program, including completing discharge/transfer notes in CPRS.
- Monitors recovery process and related medical, physical and psychological problems and other intervention defines by unit policy.
- Promotes and provides health care teaching to patients, including family members, when feasible and appropriate.
- Demonstrates ability to manage daily routine patient care and workload operations.
- Seeks to improve work processes continuously and offer suggestions for the improvement of patient care.
- Is proactive in identifying potential crises and responds appropriately in emergency situations.
- Acts as a preceptor/mentor to new staff and/or nursing students.
Requirements
- U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- Selective Service Registration is required for males born after 12/31/1959.
- Must pass pre-employment physical examination.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP).
- Graduate of a school of professional nursing approved by the appropriate accrediting agency.
- Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth of the United States.
Nice-to-haves
- Minimum of 1-2 years of case management experience, including telephone triage.
- Certified Case Manager (CCM) certification.
Benefits
- Competitive salary, regular salary increases, potential for performance awards.
- 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
- Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
- Federal health/vision/dental/term life/long-term care insurance options.
