Geriatrics Clinics provide an outpatient interdisciplinary clinic to support evaluation and management of frail elderly with various complex geriatric syndromes and dementia who are at risk for institutionalization. The interdisciplinary services provided within this clinic are expected to serve the growing geriatric population, reduce resource utilization, and improve Veteran and Caregiver satisfaction. In addition, these Services will also provide advanced geriatrics expertise and consultative support to Primary Care colleagues throughout the health care system, thus further enhancing the care for challenging, complex geriatrics cases. The Geriatric RN Care Manager (RN CM) is a licensed professional RN who is assigned to a designated panel of geriatric and dementia care veterans within Geriatrics and Extended Care. The Geriatric RN CM collaborates with other Geriatric PACT (Geri PACT and consult clinic) team members (patient, provider, Medical Support Assistant (MSA), LVN, pharmacist, social worker, etc.) and the larger team (family/caregiver, internal and community-based services) in supporting the patient-centered, patient-driven holistic plan of care to deliver and manage preventative, proactive, patient–driven care and chronic disease management and care needs effectively and efficiently. The RNCM demonstrates leadership in delivering efficient, comprehensive, and continuous patient-driven holistic care through active patient care, collaboration, communication, and coordination of resources. The RN Care Manager uses the nursing process and evidence-based practice to provide proactive preventative and patient-driven care. As a member of the Geri PACT and consult team, the RN CM is responsible for collaborating with services internal and external to the VA to facilitate and coordinate care transition to meet the patient’s needs effectively and safely. The RN CM provides patient and family health education with a focus on self -management, prevention, and wellness, based on the patient’s goals. The RN CM serves as an advocate for veterans and actively engages with his/her team and colleagues as s/he continues to enhance his/her own and the team’s professional growth, development, and practice.

Major duties include, but may not be limited to:

• Performs, reports, and records nursing care and procedures of the Veterans scheduled at the clinic and assist the LVN as needed.

• Provide coverage for LVN as needed for clinic workflow and following the orders of the providers.

• Actively participates in chronic disease management for panel in collaboration with provider.

• Engages in Shared Medical Appointments (SMA), Group visits, Team visits and/or RNCM visits.

• Maintains expertise in chronic care/disease management and Health Promotion/Disease Prevention.

• As a routine manages daily patient care alerts in CPRS and secure messages in a timely, safe, and effective manner.

• Utilizes the Primary Care Almanac and PACT Metrics to address population health management issues and improve Team processes.

• Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.

• Accurately documents coordination and care provided in CPRS. • Assists in determining appropriate scheduling based on patient’s clinical needs. Right person, right place, right time.

• Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of geriatric and dementia care Veterans across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the geriatric patient and those with dementia.

• Exhibits leadership in promoting proactive and evidence-based care by bringing up to date research and data to the team and collaborates with ancillary team members and resources within the clinic to manage clinic access issues. This may include assisting other nursing staff with maintaining clinic flow.

• Serves in a role to support Telehealth and VA Video Connect programs across the system.

• Exhibits leadership in promoting proactive and evidence-based care by bringing research and data to the team and leading process improvements to keep team practices current.

• Promotes patient, family and team interactions, and problem solving by actively participating in interdisciplinary meetings to facilitate coordination and the achievement of identified goals.

• Retains current knowledge of multidisciplinary resources, programs, and services, referring Veterans to community resources as appropriate. Demonstrates ability to collaborate and coordinate with all levels of services and disciplines.

• Collaborate with Veterans to assess and identify needs, issues, care goals, and resources for achieving desired outcomes, post hospital recovery and health maintenance/wellness by effectively using Motivational Interviewing and TEACH techniques.

• Supports patient self-management by providing an ongoing relationship with the Geri PACT with current information regarding all options, choices, and resources. Provides patient centered care while respecting patient’s personal values, cultural, and belief system.

• Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice. Exhibits leadership in promoting proactive and evidence-based care by bringing up to date research and data to the team and leading process improvements to keep team practices current and safe based on High Reliability Organization (HRO) principles.

• Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care.

• Maintains professional knowledge and skills based on current evidence-based practice.

• Maintains effective working relationships with professionals and support personnel within the medical center and the community.

• Applies critical thinking and analytical skills to identify barriers for optimal patient care delivery and utilizes processes improvement strategies to correct or improve current state.

• Utilizes creativity and innovation. Recommends and participates in interdisciplinary opportunities to improve patient care or clinical efficiency.

• As needed, provides back-up coverage for other team members within the clinic.

• Actively provides coverage for care of Veterans within GEC and Extended care services as needed.

• Actively support the organization during surge and pandemic in areas as needed.

Job Types: Full-time, PRN, Per diem

Pay: $98,514.00 - $185,540.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Health insurance

Medical specialties:

• Geriatrics
• Primary Care

Physical setting:

• Clinic
• Outpatient

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Ability to commute/relocate:

• Mather, CA 95655: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Nursing: 1 year (Required)

License/Certification:

• BLS Certification (Required)
• RN (Required)
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