Description du poste
The Community Nursing Home Program RN provides clinical oversight, case management, care coordination, and ongoing communication for Veterans receiving care in contracted community nursing home facilities. The RN is responsible for promoting continuity of care, access to services, appropriate utilization, Veteran safety, and effective transitions across VA and community care settings.
PRINCIPALES MISSIONS :
The RN works under the direction of the designated supervisor and collaborates with the Social Worker, Program Coordinator, PACT, nursing home staff, Prosthetics, Care in the Community, Hospice, and other members of the interdisciplinary team to provide coordinated, Veteran-centered care. The RN applies the nursing process by assessing, planning, implementing, and evaluating care based on the Veteran's age, health status, functional needs, psychosocial circumstances, values, culture, and preferences. Core Responsibilities Visit assigned contracted nursing home facilities every 60 days, alternating visits with the Program Coordinator. Assess enrolled Veterans during facility visits and document each encounter in CPRS. Review the Veteran's medication regimen during facility visits and care coordination activities, including medication reconciliation, indication, effectiveness, adherence, potential adverse effects, duplications, interactions, and clinical changes that may warrant follow-up. Compare medication information across available VA, nursing home, hospital, specialty, and hospice records, and communicate discrepancies or concerns to the appropriate provider, facility staff, PACT, pharmacist, and other members of the care team. Monitor for medication-related risks, including falls, sedation, hypotension, hypoglycemia, bleeding, adverse drug reactions, and other concerns relevant to the Veteran's condition and care setting. Ensure medication changes associated with admissions, hospitalizations, returns to the facility, transfers, leaves of absence, and discharges are communicated and documented appropriately. Complete and coordinate required depression screenings and updates to VA contact information at admission and annually. Maintain an accurate and current roster of Veterans enrolled in the program and report discharges to the appropriate team members. Document facility-status changes-including falls, hospital transfers, returns to the facility, and leaves of absence-in CPRS and notify program staff. Report falls promptly to the Program Coordinator and obtain all relevant clinical and incident details from the nursing home. Coordinate Care in the Community requests by obtaining required clinical documentation, forwarding information to the appropriate team, and documenting requests in CPRS. Coordinate requests for specialty equipment with nursing home staff, the Veteran's care team, and Prosthetics. Support the hospice contract approval process by coordinating physician reviews, tracking determinations, updating the hospice spreadsheet, and communicating outcomes to appropriate staff. Maintain accurate program records, shared calendars, rosters, spreadsheets, and tracking tools. Coordinate routinely with the Social Worker, Program Coordinator, PACT, nursing home staff, and other relevant clinical and administrative personnel to address medical, functional, psychosocial, caregiver, and care-transition needs. Identify psychosocial concerns and refer Veterans and families to Social Work for assistance with caregiver support, advance care planning, benefits, community resources, discharge planning, and other supportive services. Provide or coordinate patient and family education, support Veteran self-management when appropriate, and promote active participation in care planning. Administer medications and perform nursing procedures in accordance with established policies, procedures, and clinical guidelines. Collaborate with the interdisciplinary team to influence care outcomes and support safe, timely, and appropriate t
À propos de Veterans Health Administration
OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans? The Lexington VA Health Care System provides care for Veterans throughout central, eastern, and southern Kentucky. The Troy Bowling Campus near Cooper Drive in Lexington is a fully accredited, two-division, tertiary care medical center with an operating capacity of 199 hospital beds. Established in 1973 and built adjacent to the University of Kentucky, this campus offers specialty outpatient care, inpatient acute medical, neurological, surgical, and psychiatric care. The Franklin R. Sousley Campus on Leestown Road, established in 1931, is home to the main Primary Care clinics, including Women's Health and Geriatric specialty clinics. It also houses other s