Registered Nurse - Patient Aligned Care Team (PACT)

Patient Aligned Care Team (PACT) Registered Nurse (RN) functions directly to support the activities of the St. Cloud VA Health Care System Primary and Specialty Medicine (PSM). The RN is responsible for the planning, integrating, implementing, modifying and evaluating the effectiveness of the Veteran's care. The RN will focus on providing care that is unique to the Veterans needs and continues to monitor, track and intervene, if necessary, in the episode of care across the continuum.

Major duties include but are not limited to: Provides initial and ongoing assessment of patients to identify needs and appropriate resources and/or interventions necessary for care management. Applies nursing process, seeks resources, and identifies critical factors that may impact desired outcomes on discharge, post hospitalization recovery, or health maintenance/improvement. Identifies patient resources and support during anticipated declines in health.

Sets clinical care goals, short and long term, in collaboration with patients, provider(s), including the Primary and Specialty Medicine team, the Mental Health Care team, Community Living Center, and family members. Coordinates care and discharge planning with the patient's Primary and Mental Health Care providers and the health care team. Collaborate with the patient, Primary Care team, Mental Health team, the Community Living team, and other care providers in any and all settings where care is being provided to evaluate and update changes in the therapeutic plan of care and patient management.

Assesses patients for use of appropriate home medical devices including tele-health equipment, follows procedures for ordering equipment, documents instruction/education in computerized patient record. Implements extraordinary customer service skills. Implement exceptional service recovery opportunities.

Demonstrates proficiency in medication management, including accurate preparation, administration, patient education, and documentation. Collaborate with Specialty providers, nurses, and MSAs to facilitate the efficient scheduling of consults. Preferred Experience: Primary Care 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: Monday - Friday 8:00AM to 4:30PM Telework: Not Available Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.

This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.