Registered Nurse-Home Telehealth Care Coordinator

The Home Telehealth Care Coordinator Registered Nurse works to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings and high-risk patients with chronic and mental health disease. Provides initial and ongoing comprehensive assessment to include a review of systems which establishes a comprehensive plan of care. Identifies, analyzes, and prioritizes problems and interventions and sets appropriate SMART goals(Specific, Measurable, Achievable, Realistic, Time-based). Triages and assesses all data received from Home Telehealth patients such as vital signs, reported symptoms and question responses. Identifies and intervenes for potential exacerbations of complications to facilitate timely care in Patient Aligned Care Team (PACT) clinic, Emergency Department (ED)/Urgent Care (UC), and or/care in the community. The HT RN provides communication and data exchange with community-ba