Registered Nurse - Outpatient Primary Care (PACT)

Summary

The Outpatient Primary Care (PACT) Registered Nurse leads proactive, patient-centered care by using nursing protocols to improve outcomes within the immediate PACT and beyond as well as act as the primary coordinator for a designated panel of patients emphasizing health promotion, chronic care management, patient self-management support, and overall wellness.

Duties

https://www.youtube.com/watch?v=NpaTtyybXFQ Major Duties: Duties and responsibilities include, but are not limited to, the following: Care Coordination & Transition Management: Provide expertise in primary care coordination for the Patient Aligned Care Team (PACT), oversee transitions of care, develop and implement Veteran-centered nursing care, deliver preventive and chronic disease management interventions, and provide care through multiple modalities including face-to-face visits, virtual encounters, secure messaging, and telephone-based services. Utilize population health tools and evidence-based guidelines to identify and manage high-risk and chronically ill patients to improve quality of care and resource utilization at the expert level with improved outcomes beyond the immediate practice setting; Collaborate with interdisciplinary team members, at the expert level, to apply structured appointment grids, and engage in proactive panel management to optimize health outcomes, support self-management, and reduce avoidable complications. Patient Care/Customer Service: Provide proactive, evidence-based care management using clinical reminders, policy orders/nurse protocols, and population health tools, deliver chronic disease management, preventive health services, patient education, and health coaching to support Veteran-centered goals across all stages of care. Lead initiatives to improve Veteran/patient experience. Coordinate same day needs and post discharge transitions by managing procedures, labs, follow-ups, pre-visit preparation, clinical reminders, and referrals; Ensure Veterans are connected with appropriate services, specialty care, and interdisciplinary team resources. Demonstrate expertise in identifying and managing patients requiring RN care through daily huddle and team collaboration; develop individualized care, provide health coaching and motivational interviewing, and deliver ongoing management for patients with chronic and ambulatory care-sensitive conditions resulting in improved evidence-based and/or data-driven outcomes beyond the immediate practice setting. Population Identification: Lead initiatives to improve data driven outcomes by using data-driven risk indicators to identify rising and high-risk patients, prioritize focused panel management, and coordinate appropriate referrals for enhanced care management sharing best practice/improvements beyond the immediate practice setting. Stratification, Care Coordination & Transition Management: Use nursing expertise to identify gaps in care and connect patients with wraparound services; Coordinate care and ensure smooth transitions between acute and ambulatory settings for patients with chronic disease, population health, post discharge or acute needs. Lead process improvement or quality improvement initiatives to improve processes or patient outcomes beyond the immediate practice setting. Deliver ongoing RN-led chronic disease management using Veterans Affairs/Department of Defense clinical guidelines, evidence-based guidelines, health coaching, and collaboration with extended team members to support patient self-management, goal setting, and optimized clinical outcomes. Team Support & Teamwork: Collaborate with PACT core team members and the extended care support team to reach PACT goals related to access, continuity, patient experience and quality outcomes through huddles, pre-planning, and daily communication to support access, continuity, quality, and patient experience while facilitating efficient, patient-ready visits. Apply Whole Health principles and appropriate task delegation to strengthen team functioning, enhance care coordination, and meet PACT performance goals. Monitor team metrics and use VHA panel-management tools to identify care gaps, improve patient data, and lead proactive, high-quality primary care delivery. 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; 8:00 AM-4:30 PM Telework: Available (Ad-Hoc) (NOTE: The Veterans Health Administration, including the Montana VA Health Care System, will comply fully with the intention and instructions contained in the "Return to Office" Executive Order. This position will likely be eligible to telework on a limited Ad-Hoc basis only) 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 mu