Nurse PACT

Care Manager Registered Nurse

Responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care. Assesses, plans, implements, and evaluates care based on age specific components. Assumes responsibility for the coordination of care focused on patient education, self-management, and customer satisfaction throughout the continuum of care. Administers medications and procedures per established policies and guidelines. Influences care outcomes by collaborating with members of the interdisciplinary team. Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex client care. The Care Manager Registered Nurse (CMRN) is responsible for providing competent, evidence-based care to assigned patients. Provides patient management, care coordination, and discharge planning for inpatient and outpatient settings, assisting Veterans, family members, and caregivers in accessing appropriate services for complex health care needs. Coordinates care across multiple providers and settings, ensuring continuity of care within VA and community programs. Addresses psychosocial, nursing, and medical needs through interdisciplinary collaboration, expediting care from diagnosis to treatment. Manages laboratory and radiology results, utilizing databases for population management and evaluating care outcomes. Advocates for holistic care through education and provider interaction, implementing educational plans to meet patient needs. The Patient Aligned Care Team (PACT) CMRN provides outpatient primary and specialty care, supporting patients aged 18 and older. Duties include medical/surgical exams, acute illness management, preventative medicine, chronic disease management, patient education, and emotional support. Executes leadership responsibilities within the interdisciplinary team, supporting primary care providers and may take on additional roles based on experience and competency. Applies PACT principles using evidence-based practice to develop patient-driven care plans in collaboration with the team lead and expanded team. Facilitates care transitions internally and externally to meet patient needs, providing health education focused on self-management, prevention, and wellness. Acts as an advocate for patients and a leader within the team, following VA guidelines for health coaching, education, and home telehealth monitoring to improve clinical outcomes. Provides patient-centered, proactive care that is data-driven, team-based, accessible, timely, comprehensive, and coordinated. Acts proactively to anticipate future situations, engaging patients as partners in their care and building strong patient-provider relationships. Delivers health education spanning the continuum of care, including clinical preventive services aimed at promoting health, preventing disease, and minimizing future morbidity and mortality.

US Department of Veterans Affairs