Summary

Home Telehealth Care Coordinator (HTCC) Registered Nurse (RN) demonstrates leadership - experience - and creative approaches to management of complex patient care. The HTCC is responsible for coordination of health care for a defined patient population - identified as high resource users or at high risk for decline. Patients receive goal-oriented - coordinated care addressing holistic needs with the aim of preventing disease complications - maximizing functional ability - and quality of life.

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 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/13104796
• 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/
• Preferred Experience: Case Management Experience within the last 5 years - Preferred Care Coordination/Patient Aligned Care Team/Primary Care Experience - Preferred Traumatic Brain Injury/Mental Health/Chronic Care Experience - Preferred Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service for requirements.

Duties

• The functions and responsibilities of the HTCC include but is not limited to: Adhering to established policies - standards of care and standards of practice is consistent with the plan of other health care providers Coordinating and facilitating the provision of clinical and psychosocial services in a setting best suited to the services and to the healthcare needs of assigned patients
• Implementing measures to improve access to care and the provision of timely health care interventions
• Working collaboratively with the patient - family/significant other - and members of the interdisciplinary team to implement a plan of care across the continuum to meet each patients individual needs and maintain or improve quality of life
• Promoting strategies that contribute to the effective and efficient use of Medical Center and VISN resources
• Providing care for his/her panel of patients through tele-health technology engaging the patient in self-responsibility for healthcare agency (can you? will you?)
• Being accountable for patient care follow-up to meet established clinical guidelines/performance measures
• Reviewing consults of patients to assign telehealth technology - coordinating follow-up care for patients across the continuum - and providing interventions to reduce hospitalizations and ER visits in collaboration with the Primary Care Team
• Enhancing patient satisfaction and patient advocacy
• Providing consultation to other health care providers - disciplines - and departments
• e.g
• Home Telehealth for optimizing blood glucose in diabetic patients
• Teaching other members of the health care team regarding clinical - fiscal and system processes related to nursing case management with home telehealth technology
• Providing data about indicators related to clinical and fiscal outcomes
• Collecting - analyzing - and sharing of data and information in order to influence performance improvement goals
• Providing leadership in the application of the nursing process to client care - organizational processes in order to improve outcomes at the program level
• Serving as a liaison to the patient - his/her family - and members of the multidisciplinary team and hospital systems - to facilitate the management of patient-centered care\" right care - right place - and right time
• Adhering to appropriate interpersonal skills - working closely with all members of the interdisciplinary team
• Assuming the role of educating staff to meet changing program or service needs and consulting regarding issues such as care planning - policy interpretation and others
• Responsible for the documented outcomes at the program or service level
• Program of service level outcomes must be broad and complex and can be demonstrated at any organizational level
• 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: Full-Time Telework: Not Available
• Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not Authorized.