Home Based Primary Care (HBPC) Registered Nurse

Summary

The Home-Based Primary Care (HBPC) Registered Nurse provides comprehensive, patient-centered nursing care to Veterans with complex, chronic, or disabling conditions who receive care in their homes. The RN is a professional nurse who evaluates and analyzes care provided to patients to assure it is timely, appropriate, of high qualify, and cost effective. The RN is a key member of an interdisciplinary team that includes various health professionals at the Oakland VA Outpatient Clinic.

Duties

The HBPC RN is responsible for ongoing assessment, care coordination, health promotion, patient education, and disease management for assigned Veterans. This role emphasizes preventive care, chronic disease management, and maintaining the Veteran's highest level of independence and quality of life in the home environment. The nurse performs in-home visits, monitors health status, administers prescribed treatments, collaborates with providers to develop individualized care plans, and ensures compliance with VA standards, policies, and regulatory guidelines. The RN also supports telehealth and outpatient coordination as needed, contributing to continuity of care between home and clinical settings. Key Responsibilities: Assess, evaluates, plans, implements, and coordinates care, and confers with other Home Based Primary Care providers to evaluate and initiate changes to ensure quality care. Helps Veterans to self-manage chronic diseases such as diabetes, hypertension, congestive heart failure, chemical dependency, cancer, dementia, and any other conditions that may warrant additional attention. Triages and applies collaborative team approach in identifying, analyzing, and resolving Veteran's care problems, and develop care goals for resolving or managing these issues. Focuses on wellness and patient education, and uses motivational interviewing techniques to help the Veteran meet his/her goals. Collaborates with services, internal and external, to facilitate care. Maintains a current knowledge of interdisciplinary resources, programs and services to include community resources as appropriate. Establish methods to monitor patients' progress, including performing injections, venipunctures and catheter care and management and maintain appropriate documentation within designated timeframes. Conduct comprehensive home assessments and develop individualized nursing care plans. Manage chronic conditions, provide wound care, medication management, and health education. Coordinate multidisciplinary care to support Veterans' physical, emotional, and social well-being. Document care activities and outcomes in the electronic health record (EHR). Participate in quality improvement initiatives and case conferences. Promote safety, independence, and prevention of hospitalizations. 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: 8:00am-4:30pm hours vary on patient care needs Telework: Ad-hoc available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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/13108915. 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 ot