Department of Veterans Affairs
The Community Nursing Home (CNH) Coordinator Registered Nurse (RN) is responsible for providing competent, evidence-based care to assigned patients by providing patient management, care coordination, and discharge/disposition planning for both internal and community providers and is responsible for managing the care of the Veteran throughout the CNH contract.
- Duties include but are not limited to: Assisting Veterans, family members, and caregivers with receiving the most appropriate options and services to meet their complex health care needs, which 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. Coordinating 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. Developing and coordinating seamless transitioning of patients throughout the inpatient care process with a focus on discharge planning needs. Reviewing and assisting 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. Serves as a liaison to both internal and community providers and is responsible for managing the care of the Veteran throughout the CNH contract. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Work Schedule: Monday - Friday, 0800-1630 Telework: Not available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized
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