CASY-MSCCN Jobs

The Licensed Practical Nurse is responsible for assisting the Patient-Aligned Care Team (PACT). The Licensed Practical Nurse is responsible for basic duties as listed below and other duties as assigned:

Ensure appropriate evaluation and access is provided to patients assigned to the patient panel.

Utilize all available tools, such as registries, to enable effective and efficient identification and intervention of individual patients and cohorts.

Function at the full extent of the team member's scope of practice based on experience/training.

Participate in team performance improvement and sustainment activities to enhance care delivery to patients.

Implement primary care operations management processes as appropriate; access, Veteran centered care, Life Goal, etc.

Manage communications and facilitate safe transitions of the Veteran between the PACT and other health care settings using warm hand-off communication either in person or by telephone.

Provide health education on wellness, disease prevention, chronic care management and self-management skills to patients and personal support persons, based on the documented expertise or professional training of the PACT member.

Use informal/formal communications that are respectful, effective, and timely with all team members and other internal/external customers to convey significant, clinically relevant information for the care of the patient.

Collaborate with informatics technology staff to develop and implement systematized, electronically supported, standardized, tools to support PACT care delivery processes (e.g., pre-visit reminder calls, post-hospitalization follow-up calls, recall scheduling procedures, new patient orientation, disease registries and primary care protocols for chronic disease management) as needed.

Responsible for specific role assignments, including:

• Participate in PACT huddles/meetings
• Participate in process improvements and system redesign
• Promote personal, pro-active, Veteran Centered care
• Use shared decision making
• Assist with pre-visit phone calls to Veterans to complete reminders as appropriate and obtain reason for appointment if not indicated.
• Review daily clinic schedule for patient care needs
• Collaborate with PACT members to develop comprehensive health care plans and care management plans for Veterans assigned to panel.
• Use motivational interviewing and apply TEACH techniques to guide patients in setting goals.

Manage clinic flow which includes the following:

• Vital signs and treatments as indicated/appropriate
• Complete appropriate clinical reminders
• Assist the provider with exam/procedures
• Administer and track immunizations
• Prepare and administer medications
• Complete orders per provider or protocol
• Keep providers on schedule
• Keep Veterans advised of delays/wait times
• Ensure visit closure
• Observe, record and report patient's response or changes in patient's condition
• Promptly recognize and respond to urgent or emergent situations
• Assist with orientation of new employees.
• Coordinate group visits.
• Check daily equipment/supplies and restock the exam rooms
• Promptly recognize and respond to urgent or emergent situations.
• Participate in group visits with team members
• Follow medical center policies
• Act as patient advocate; assuring patient understands content of visit and when to return to clinic, as well as how to contact team between visits.
• Promote patient and personal safety.

Assist Care Manager in coordinating care for patients assigned to the PACT when Veterans are:

Walking into the clinic without an appointment (take vital signs and gather data)

Discharged from non-VA hospitals or seen in non-VA Emergenc