The RN Home Telehealth Care Coordinator coordinates care for a panel of patients throughout the continuum of care to assure care is timely, appropriate, of high quality and cost effective. Works closely with primary care provider (or providers) and other healthcare professionals and team members, other clinics, internal or external services and community agencies. This position is part of Patient Care Service at the C.W. Bill Young VA Medical Center, Bay Pines, Florida. The RN Home Telehealth Care Coordinator has continuous responsibility for the following duties (but not limited to): Provides professional assessment; coordination and planning of multiple health care services; and acts on behalf of the veteran to assure that necessary clinical services are received, and that progress is being made. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. Utilizes treatment plans to assess, identify, analyze, and prioritize problems, interventions and appropriate measurable goals (i.e., Simple, Measurable, Achievable, Realistic, Time-oriented (SMART) goals). Recognizes impact of age-specific care needs and incorporates this into the assessment process. Also, incorporates these age-specific needs into care as reflected by modification of treatment plans. Applies care and case management principles to coordinate care using health informatics, disease management and technologies, such as in-home or mobile messaging devise to facilitate access to care and to improve the health of Veterans with the specific intent of providing the right care in the right place at the right time. Communicates with all services within the medical center and is responsible for coordinating care in a cost-efficient manner. Coordinates patient care and collaborates with other disciplines/departments to achieve patient care outcomes. Triage and assess all data received from Home Telehealth patients such as vital signs, reported symptoms, and question responses. Contact patients with high risk responses, significant changes in condition or changes in other specific data elements received. Triage calls and concerns of patient/family resolve those within scope of practice and route others to primary care staff or other services as indicated. Identifies patients' knowledge, health factors, skills, and behaviors that support self-management and identify gaps therein. Communicate with provider regarding progress to goals; patterns or trends of data, symptoms, or findings; concerning findings; need for provider assessment and/or interventions. Assesses patients for use of appropriate Telehealth devices, follows procedures for ordering through Remote Order Entry System (ROES), documents installation and education in computerized patient record system. Work Schedule: Monday - Friday, 7:30am - 4:00pm Financial Disclosure Report: Not required
Internal Number: 598449600
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.