The Discharge Planner Registered Nurse (RN) position reports to the Centralized Nurse Staffing Office and Utilization Management Nurse Manager or designee. It is a care coordination role within the Utilization Management program at VA San Diego healthcare System (VASDHS). The discharge planner is responsible for coordinating the discharge process for patients leaving the hospital. 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/12577117. 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 others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: Heavy lifting (45 lbs and over); Heavy carrying (45 lbs and over); Straight pulling and pushing; reaching above shoulder; use of fingers; both hands required; walking and standing up to 8 hours; repeated bending; Ability for rapid mental and muscular coordination simultaneously; hearing aid permitted. ["VA offers a comprehensive total rewards package: VA Nurse Total Rewards The Discharge Planner is an integral member of the interdisciplinary team inclusive of physicians, social workers, case managers, physical therapists, pharmacists, and nutritionists. The goal of discharge planning is to prevent readmissions and promote continuity of care for the patient. Major duties and responsibilities: 1. Completes an admission assessment including anticipated needs for continuity of care and discharge planning and documenting this information in the electronic health record. 2. Collaborates with the interdisciplinary team to ensure a comprehensive and holistic approach to care for veterans. 3. Facilitation and tracking of attendance during interdisciplinary rounds. 4. Provide support and guidance to veterans and their families throughout the discharge process. Evaluate veteran and family response to guidance and provide reinforcement as necessary. Document all instructions given and an evaluation of the response in the electronic health record. 5. Completes the nursing review of the Geriatric Extended Care referral to skilled nursing and other VA continuing care programs, indicating the anticipated post hospitalization nursing needs of the Veteran. 6. Collaborates in the development of discharge/home care plans based on needs identified and resources available. 7. Performs home care needs assessment on high-risk Veterans returning home. 8. Coordinates discharge plans and referrals to home health care or hospice services with Veteran, significant others, facility staff and community agencies. 9. Advocates for veterans to receive necessary resources and services post discharge. 10. Ensures seamless communication between the veteran, healthcare providers, and community resources for a successful transition out of the hospital. 11. Utilizes InterQual criteria to review appropriateness of level of care and recommendations. Adheres to VHA Directives and local policies for discharge planning. 12. Performs other duties as assigned. Preferred Experience: Education: Required BSN, preferred MSN or Master's in Healthcare Related Field Minimum 3 years acute clinical care experience Preferred case management certification BLS certification required Strong knowledge of relevant healthcare and clinical operations including information technology (preparing reports, MS Office Suite, and computer knowledge) patient care workflows and processes. Demonstrate organizational and project management skills, with the ability to lead a team, prioritize tasks, and see projects through from inception to completion. Strong analytical and critical thinking skills, with the ability to quickly analyze problems, determine appropriate level of intervention, and develop and apply effective solutions. Strong interpersonal skills for effective information exchange and problem solving with all levels of management and staff, consultants, and outside agencies. Flexibility and ability to work in a rapidly changing environment. Self-starter with good time-management skills. 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 Hour, Variable Tour to meet operational needs of the facility, Weekends and holiday may be required Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized"]
The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.