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Registered Nurse - Home Telehealth

The Home Telehealth RN is directly responsible to the Director of the Home Telehealth area or their designee.
The RN is responsible and accountable for the provision of patient care and for the delivery of quality nursing care to a culturally diverse Veteran patient population.
The RN possess the knowledge and skills to effectively apply all aspects of the nursing process within a collaborative, interdisciplinary practice setting, which will then enable effective implementation of health promotion and prevention practices, management of acute and chronic illnesses, and attainment of optimal levels of functioning and/or support of the dying patient and significant others.
Role and responsibilities and accountabilities also include demonstration of knowledge and skills necessary to provide care appropriate to the age related needs of patient served.
This knowledge includes understanding changes associated with aging and principles of growth and development relevant to the adult and geriatric population.
The Home Telehealth (HT) Registered Nurse is responsible for the 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.
The HT RN provides information about services in the healthcare delivery system such as treatment and care options, community services, home care options, and home Telehealth technology equipment.
The functions and responsibilities of the HT RN include the following:
Adhering to established policies, standards of care and standards of practice is consistent with the plan of other health care providers.
Adhering to established policies, standards of care and standards of practice such as treatment and care options, community services, home care options, and home Telehealth technology equipment.
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 patient's 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 Telehealth 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 future 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, their 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 interpretations, and others.


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