RN (PACT Care Coordinator)

Work Schedule:
IntermittentFunctional Statement Title/#:
The incumbent of this position will work for the VA Palo Alto Health Care System as a direct provider who has the technical proficiency, excellent observation skills necessary for initiating, performing, and completing assigned duties in delivering comprehensive practical nursing care to variable patient populations.
The incumbent is a member of the Patient Aligned Care Team (PACT) (Patient, Primary Care Provider, RN Case Manager and Patient Support Technician) and Expanded Team (family/care giver, internal and community based services) involved in providing care to the patient and in developing the patient aligned care plan.
The major duties and responsibilities include but are not limited to:
Triages and applies a collaborative team approach in identifying, analyzing, and resolving patient care problems.
Collaborates with patients to assess and identify needs, issues, care goals, and resources in critical factors for achieving desired outcomes for discharge, post hospital recovery and health maintenance/wellness.
Demonstrates ability to collaborate with all levels of services and disciplines.
Collaborates with patient, family and care providers in any and all settings where care is being provided to evaluate and update changes in the patient-driven life plan and patient management.
Actively participates in care delivery with priority attention to patient preference.
Promotes wellness by empowering the patient to self-management through education and patient-driven health care delivery.
Promotes patient, family and team interactions and problem solving by actively participating in interdisciplinary meetings to facilitate collaboration and the achievement of identified goals.

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