Summary

The Home Based Primary Care RN Case Manager provides nursing assessment - care coordination - skilled nursing care - and chronic disease management in the homes of Veterans including private residences - residential care facilities - assisted living facilities in collaboration with the HBPC interdisciplinary team. HBPC nursing practice is focused on longitudinal and comprehensive primary care - rehabilitation - disease management - caregiver assistance - and integrative case management.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate 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)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• 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
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12813786
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: Heavy Lifting (45 lbs and over)
• Straight Pulling - Pushing - Walking - Standing - Repeated bending (8 - 12 hours)
• Reaching above shoulder
• Use of fingers
• Both hands and legs required
• Ability for rapid mental and muscular coordination simultaneously
• Near vision correctable at 13" to 16" to Jaeger 1 to 4
• Far vision correctable in one eye to 20/20 and 20/40 in the other
• Both eyes required
• Depth perception
• Ability to distinguish basic colors and shades of colors
• Hearing (aid permitted)
• Emotional/Mental stability
• Keyboarding and reading computer screen (8-12 hours intermittently over scheduled shift).

Duties

• The HBPC RN assumes the following major duties and responsibilities: 1
• Develops and manages the individualized patient plan of care to include ongoing assessment - care planning - care coordination - monitoring - and evaluating clinical outcomes
• 2
• Provides health teaching - health counseling - provision of care supportive to restorative to life and well-being
• 3
• Provides skilled primary care nursing interventions in the home such as vaccinations - urinary catheter changes/maintenance - and venipuncture/specimen collection
• 4
• Provides nursing medication management - education - and monitoring
• 5
• Documents patient care assessments - interventions - care coordination - quarterly reviews - and care plan outcomes in the electronic medical record
• 6
• Provides nursing care coordination to ensure comprehensive service delivery including referral to resources/clinical services within the VA San Diego Healthcare System and/or community agencies
• 7
• Plans - schedules - and completes nursing visits in the home - clinic - by phone - or using approved video technologies
• 8
• Provides comprehensive nursing case management through communication with the HBPC Interdisciplinary team - specialty clinics/services - inpatient acute care - transportation services - community home care agencies - community hospital/providers - Caregivers - skilled nursing facilities and RCFE staff
• 9
• Maintains a panel of Veterans requiring ongoing chronic disease management and nursing interventions
• 10.Provides leadership in unit performance improvement - shared governance - HRO - and system redesign initiatives
• 11.Maintains a valid and unrestricted driver's license for travel to Veteran homes and various VASDHS locations during both day and night time tour of duty hours
• 12
• Follows policies for care and maintenance of assigned government vehicles
• 13.Serves as a preceptor and/or clinical resource for nursing and HBPC interdisciplinary team
• 14.Develops/Updates unit-based policies and standard operating procedures
• 15.Participates on local - VISN - and/or national HBPC committees - councils - or workgroups
• 16.Performs other duties as assigned
• Preferred Experience: 1
• Three years recent full time experience as an RN 2
• One year nursing practice working with complex patient populations in the home care environment
• 3
• RN Certification in one of the following: Case Management - Geriatrics - Care Coordination & Transition Management
• 4
• Experience working in a autonomous nursing role
• 5
• Experience in home venipuncture and IV Therapy
• 6
• Contributions to performance improvement or evidenced-based activities in nursing practice
• 7
• Training in Shared Governance - Relationship Based Care - and/or High Reliability Organizations
• 8
• Unrestricted Drivers License and ability to drive in Day or Night Conditions
• VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary - regular salary increases - potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday - Friday 0730-1600 Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized