REGISTERED NURSE - COMMUNITY NURSING HOME COORDINATOR

Summary

Delivers fundamental knowledge-based care to assigned clients while developing technical skills. Assesses - plans - implements - and evaluates care based on age-specific components. Evaluates care and outcomes to ensure timely and appropriate provision of services. Assumes responsibility for the coordination of care focused on patient education - self-management - and customer satisfaction throughout the continuum of care.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of 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)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (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 professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment:
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Preferred Experience: Resident nurse assessment coordinator or nursing home administration of one year Reference: For more information on this qualification standard - please visit
• Physical Requirements: See VA Directives and Handbook 5019 - Employee Occupational Health Service.

Duties

• Responsibilities include - but are not limited to the following: The Registered Nurse Community Nursing Home (CNH) Coordinator focus is on individual growth and development in practice with increased levels of self-direction
• This nurse brings principles and theory with limited application of critical thinking skills
• Provides patient management - care coordination - and discharge/disposition planning for inpatient and outpatient settings
• The CNH Coordinator assists Veterans - family members - and caregivers with receiving the most appropriate options and services to meet their complex health care needs
• This includes - but is not limited to - acute - chronic - multiple - complex - catastrophic - or life-threatening illnesses
• combat stress - residuals of traumatic brain injury
• community adjustment
• addictions and other health problems
• Coordinates care with multiple providers across all levels and sites of care
• Coordination includes assuring services interface within the Veterans Affairs (VA) and CNH programs to provide continuity of care to patients
• The CNH Coordinator is required to travel routinely to fulfill responsibilities within the Community Care Community Nursing Home (CNH) Program
• Travel includes visits to contracted Community Nursing Home facilities for patient assessments - ongoing monitoring - quality assurance reviews - staff education - and collaborative meetings with facility leadership
• The nurse may also be required to travel for outreach - training - and coordination activities with internal VA partners and external community providers
• Travel may be scheduled or unscheduled based on patient care needs - safety concerns - regulatory requirements - or emergent issues within contracted facilities
• The CHN Coordinator must maintain reliable transportation and the ability to travel throughout the CNH service area to ensure timely - comprehensive oversight of Veteran care
• The CNH Coordinator performs clinical nursing review of medical records of patients who are hospitalized in non-VA hospitals to determine point of stability for payment purposes and potential for transfer of the Veteran to a VA facility for care
• Possesses knowledge of utilization management processes - clinical documentation requirements - current standards of care - and compliance guidelines
• Maximizes third-party payments for care and delivering quality patient care performance improvement activities
• The CNH Coordinator develops and coordinates seamless transitioning of patients throughout the inpatient and outpatient care process with a focus on discharge planning needs
• Reviews and assists in patient referrals to CNH facilities to ensure continuity of qualified comprehensive care
• Participates as needed in the discharge planning assessment and implementation of community health services - to include skilled nursing care - hospice - adult day health services - respite services and activities required to successful transition the patient to the appropriate non-acute care setting
• Performs follow-up and oversight visits to the Veteran after admission to the CNH to ensure that adequate and safe care is being provided while under VA contract
• Advocates for holistic care through patient/family education and provider interaction and implements an educational plan to meet the patient care needs
• 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: 7:30AM- 4:00PM Compressed/Flexible: Not Authorized Telework: Not Authorized Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.

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