The Housing and Urban Development -Veterans Affairs Supportive Housing (HUD-VASH) Registered Nurse Case Manager (RNCM) practices in the Outpatient Mental Health (OPMH) Clinic for VASLCHCS. The RNCM will provide assessment and intervention services for patients engaged in the Homeless and Justice Clinical Recovery Program (HJCR). The RNCM will provide assessment and intervention services for patients engaged in the Homeless and Justice Clinical Recovery Program (HJCR). Patient populations include Veterans who present with the full range of DSM-5 mental disorders, including mood disorders, anxiety disorders, psychotic disorders, and substance use disorders. Patients are likely to present with co-morbid medical conditions, functional decline, and unstable living conditions. The RNCM executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex client care. The RNCM functions as part of the interdisciplinary HJCR team. Mental health treatment provided is documented within prescribed guidelines in CPRS. This position provides services within HJCR both on site and in the community. Duties include but are not limited to the following: Responsibilities will be within the HJCR program on site and in the community providing services across the HJCR team. Demonstrates advanced clinical knowledge in assessing, planning, implementing, documenting, and evaluating care for a panel of patients across the continuum of care, recognizing the age related cognitive, physical, emotional, and chronological maturation needs of the adult and geriatric patient. Participates in chronic disease management for panel in collaboration with provider; engages in Shared Medical Appointments (SMA), and/or RNCM visits. Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems. Assesses patients and provides additional support between visits as needed; provides outreach to patients who are having problems with treatment adherence. Provides psychosocial support, assists with problem solving, development of coping skills, and supports the Veteran's personal goals for recovery. Assists in determining appropriate scheduling based on patient's clinical need. Right person, right place, right time. 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 patients for community resources as appropriate; demonstrates ability to collaborate and coordinate with all levels of services and disciplines. Serves as liaison to the Inpatient Psychiatric Unit as needed to facilitate continuity of care post-discharge. Utilizes approved Protocols and Guidelines to facilitate autonomy in providing care. Works at the top of scope of practice. Maintains competency in the administration of long-acting injectable medications according to policy. Accurately documents coordination and care provided in CPRS and HOMES. Manages patient care alerts in CPRS in a timely, safe and effective manner. Serves as a resource for patient and family rights, responsibilities, and decision-making information and processes; provides patient and family education regarding their illness, medications, and treatment plan. Functions as an advocate for Veteran self-determination and provides patient-centered care while respecting patient's personal values, cultural, and belief system. Actively participates in reviewing and updating policies, procedures, and standards to promote evidence-based, patient-driven care. 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. Coordinates and participates in community events including annual Homeless Veterans Stand Down. Uses GSA vehicles in order to complete work in the community. Assists with education and supervision of others who provide nursing care, i.e. LPNs, nursing students; assists with clinical supervision of Peer Support Specialists. Provides back-up coverage for other team members and other PACT RNCMs within the clinic as needed. Other duties as assigned. Work Schedule: Monday-Friday 8:00 am to 4:30 pm. Telework Authorized: Dependent upon program and agency needs. Financial Disclosure Report: Not required
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.