The Transition of Care (ToC) Nurse Case Manager is a registered, professional nurse who is an integral part of the Primary Care Service that delivers high quality patient care through a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the veteran's and caregiver's health care needs through communication and available resources to promote quality and cost-effective outcomes. The ToC Nurse Case Manager's primary target population are veterans admitted to and discharged from non-VA facilities, or as assigned. The ToC Nurse Case Manager addresses the Veteran and their caregiver's needs that is inclusive of medical, psychosocial, behavioral, spiritual, eligibility, and financial barriers to help transition to the appropriate level of care after hospital discharge, to avoid hospital readmission and to reconnect Veterans back to the VA system or their PACT Team for continuity of care. The ToC Nurse Case Manager directly reports to the Chief Nurse of Primary Care Service. Major duties and responsibilities include, but are not limited to: Works in partnership with external VA customers including non-VA Hospital discharge planners, physicians, Social Workers for early identification of Veterans admissions and definitive care plan prior to non-VA hospital discharge, including assessment of the appropriateness of the requested services, medical supplies, and appliances and to mitigate 30-day hospital readmissions. Works in partnership with internal VA customers including but not limited to PACT Teams, Community of Care, GEC, CLC, Behavioral Health for early discharge planning and utilization of VA resources to best meet the Veterans health care needs and to mitigate 30-day hospital readmission. Acts as a liaison between the Veteran and their care team. Maintains excellent customer service and community relationships. Act as adjunct to the PACT Team by providing support and education when needed regarding the discharge processes. Serve as an educational resource to hospital or nursing facility staff concerning VA benefits and services. This includes conducting in-services to both clinic and hospital staff. Maintain knowledge of VA and Medicare Regulations and restrictions related to admissions, supplies, and home health services, working closely with VA Community Care. Assists in obtaining physician signatures on urgent consults and orders as needed or requested. Ensures post-discharge follow-up with the PACT Team within 7-10 days of discharge or as needed. Refer timely complex discharge medications to ToC pharmacist to reconcile facility and home medications among veteran and physicians to ensure correct medication system administration is in place. Participate in data collection for tracking and monitoring of veterans assisted by the team and to provide daily update on status on caseload. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm Financial Disclosure Report: Not required
Internal Number: 599896900
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.