RN Case Manager for Home Based Primary Care
Department of Veterans Affairs
Veterans Affairs, Veterans Health Administration
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1 vacancy in the following location:
Nurses in this role provide care to Veterans in the home setting.
The service area for HBPC is within a 35- mile drive radius from the
VA. Veterans served have complex medical issues, have difficulty
getting to the Medical Center, and require closer monitoring than
clinic settings can provide. Diagnoses include: diabetes, congestive
heart failure, COPD, dementia, and Parkinson's disease. Medication
compliance and chronic disease management are major reasons for
referral to HPBC.
Learn more about this agency
Primary functions of the HBPC Nurse:
- Receive the referral from the Nurse Manger
- Consult with inpatient discharge coordinators, nurses and social
- Contact the Veteran or caregiver to schedule an in home
- Review the Veterans CPRS chart
- Make initial home visit for assessment. Assessment of the home
psychosocial, emotional and mental status; medications; home
environment and safety; caregiver/support system; and
- Based on the assessment, an initial plan of care is developed
- Also based on the assessment, referrals are made to other
- All team members involved develop an Interdisciplinary Plan of
responsible for updating and maintaining the plan of care, which
is reviewed every 90 days during the team meeting, or as needed
based on changes in the Veterans condition.
- The HBPC RN functions as the patient's Case Manager and assists
- The HBPC nurse makes home visits on a frequency determined by
Services are provided Monday through Friday from 0730 to 1600.
During off duty hours, patients are instructed on how to obtain
care if needed by contacting Urgent Care at the MVAHCS or by
calling 911 in case of emergency.
- HBPC nurses assist Veterans and caregivers develop a plan in
- Management of medications is an important part of the HBPC
in the home to ensure they are correct and match the current
orders from VA physicians. They are examined for correct storage
and expiration dates. The nurse educates the Veteran regarding
their medications and provides a current Medication Instruction
Sheet for use in the home.
- The HPBC nurse also assesses for any over the counter
this information to the primary provider for further evaluation.
- Works closely with the HCC pharmacist to ensure patient safety
- At subsequent home visits, the nurse assesses ongoing needs and
specimen collection and INR monitoring. RN confers with the
physician or other disciplines as appropriate.
- Referrals to prosthetics for appropriate equipment.
- Monitor use of oxygen therapy and safe use of oxygen in the
- Interface with community providers of service such as hospice
and homemaker services to ensure optimal care as needed.
- Discharge planning by assisting the Veteran and caregiver in
- Documents care in the appropriate CPRS note.
- Documents admissions and discharges in the Austin system.
- Participate in performance improvement activities as determined
- Participate in HBPC team meetings.
- Cleans RME (Reusable Medical Equipment) per SOP (Standard
Key competencies, in addition to baseline staff nurse competencies,
- In depth knowledge of home assessments, planning, and care.
- Ability to work independently in the home setting
- Possesses knowledge of growth and development of the adult and
- Ordering of pharmacy OTCs and supplies.
- Venipuncture and accessing central lines.
- Perform Mini-mental and/or Mocha cognitive exam
- Knowledge of both the admission and discharge process for
- Knowledge of adaptive equipment available for specific
- Knowledge of community resources for elderly disabled
- The ability to effectively communicate with interdisciplinary
- Time management skills
- Organizational skills
- Interpersonal skills
- Executes position responsibilities that demonstrate leadership,
- CVT/Telehealth visits
Monday - Friday 0700-1530
Monday - Friday 0730-1600
Monday - Friday 0800-1630
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- You must be a U.S. Citizen to apply for this job
- Designated and/or random drug testing required
- Selective Service Registration is required for males born after
- You may be required to serve a probationary period
- Subject to a background/security investigation
- Must be proficient in written and spoken English
- Selected applicants will be required to complete an online
- Must pass pre-employment physical examination
To qualify for this position, applicants must meet all requirements
by the closing date of this announcement, 09/12/2019.
- United States Citizenship: Non-citizens may only be appointed
accordance with VA Policy.
- Graduate of a school of professional nursing approved by the
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). In cases of graduates of foreign
schools of professional nursing, possession of current, full,
active and unrestricted registration will meet the requirement
of graduation from an approved school of professional nursing.
OR The completion of coursework equivalent to a nursing
degree in a MSN Bridge Program that qualifies for professional
nursing registration constitutes the completion of an approved
course of study of professional nursing. Students should submit
the certificate of professional nursing to sit for the NCLEX to
the VA along with a copy of the MSN transcript. (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
- Current, full, active, and unrestricted registration as a
Commonwealth (i.e., Puerto Rico) of the United States, or the
District of Columbia.
Required Experience: 2-3 years RN experience
Grade Determinations: The following criteria must be met in
determining the grade assignment of candidates, and if appropriate,
the level within a grade:
- Nurse I Level I - An Associate Degree (ADN) or Diploma in
- Nurse I Level II - An ADN or Diploma in Nursing and
or Diploma in Nursing and a bachelor's degree in a related field
with no additional nursing practice/experience; OR a Bachelor's
of Science in Nursing (BSN) with no additional nursing
- Nurse I Level III - An ADN or Diploma in Nursing and