Advanced Practice Nurse - Community Living Center and Home-Based Memory Care

About the role

The VA Black Hills Health Care System (VA BHHCS) is seeking an Advanced Practice Nurse (APN) Nurse Practitioner (NP) to care for Veterans at the BHHCS Community Living Center (CLC) with the expectation to expand services to our Veterans with neurocognitive disorders, focusing on caring for Veterans with dementia in the CLC and as a provider of a Home-Based Memory Care (HBMC) team.

Responsibilities

• Obtains medical histories and performs physical examinations, at admission to CLC or Home-Based Primary Care (HBPC) team and annually.
• Documents Discharge Note and Discharge Summaries at the time of discharge.
• Provides and coordinates medical care for assigned patients, including establishing diagnoses, formulating, and implementing care plans, and providing follow-up care.
• Orders and interprets diagnostic testing results and therapeutic modalities, including but not limited to laboratory tests, ECG, radiological studies, oxygen, etc., based on the current CLC treatment guidelines of stable patients.
• Orders ancillary services, including but not limited to, pharmacy, social services, physical medicine and rehabilitation therapies, prosthetic services, etc. and attend CLC Interdisciplinary Team to coordinate care for CLC Veterans.
• Orders VA specialty service consults and initiates requests for non-VA medical care and consults in accordance with VHA and local facility policy and procedures. Orders interfacility transfers and other transportation for CLC Veterans.
• Orders or prescribes devices, supplies, and durable medical equipment.
• Orders or prescribes medications for patients under their care.
• Conducts Goals of Care Conversations with high-risk patients regarding any desired limitation in life-sustaining treatments and choice of surrogate as well as enter the Life-Sustaining Treatment Decisions (LST) progress note and corresponding orders when Veteran is under their care or if delegated by the attending physician.
• Telehealth Modalities may be utilized for the provision of care by an authorized provider pursuant to Service level guidance, required training and instruction, and in collaboration with the Facility Telehealth Coordinator (FTC).
• Provides clinical oversight and participates in peer review of other Rehabilitation and Extended Care (REC) providers through periodic chart reviews.
• Acts as a surrogate for absent CLC providers as needed, to include review of EMR view alerts and other duties as assigned.
• Regularly attends all provider meetings, departmental meetings and medical staff meetings as requested.
• Conducts home visits to assess needs of patients and their caregivers enrolled in home-based primary care and the home-based memory care team.
• Performs comprehensive medical assessments/evaluations in the patients' home setting with consultation with Medical Director, as needed.
• Performs medication reconciliation in home setting.
• Manages and treats medical conditions in the home setting, involving Medical Director as needed.
• Formulates multi-disciplinary treatment plans.
• Provides health education to patients and their caregivers.
• Responds to telephone calls from patients and caregivers regarding their health care.
• Captors with community nursing home program liaison and CLC admissions team, and at times the state Veterans' home and community nursing homes for continuity of care of veterans with neurocognitive disorder as the disease progresses and they need skilled nursing home care.
• Refers patients to appropriate community or VA programs.

Qualifications

• Advanced Practice Nurse (Nurse Practitioner)
• Basic Requirements:
• Education: Post-master's certificate or master's or doctoral degree as a Nurse Practitioner.
• Licenses: Active, current, full, and unrestricted APN license to practice as an NP in a State, Territory or Commonwealth of the United States, or in the District of Columbia.
• Board Certification: Full and current basic board certification in one of the following: Family Nurse Practitioner (FNP), Adult Nurse Practitioner (ANP), Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP), Acute Care Nurse Practitioner (ACNP), Adult-Gerontology Acute Care Nurse Practitioner (AGACNP), or Gerontology Nurse Practitioner (GNP) from one of the following: the American Nurses Credentialing Center (ANCC), American Academy of Nurse Practitioners Certification Board (AANPCB), or other nationally recognized certifying body in the area in which the Nurse Practitioner is academically prepared.