Nurse (Community Living Center Care Coordinator/Staff RN)

Responsible and accountable for all elements of the nursing process when providing and/or supervising direct patient care in the Community Living Center (CLC). Collaborates with the interdisciplinary team to identify and place Veterans appropriate for CLC admission, focusing on education, self-management, and customer satisfaction.

Duties

The CLC Registered Nurse (RN) Care Coordinator demonstrates leadership, experience, and creative approaches to the management of complex resident care.

Admission Screening & Placement

• Serves as an active member of the interdisciplinary team with primary focus on CLC screening and placement processes.
• Maintains a keen understanding of the admission criteria for each program area.
• Collaborates with healthcare system members and stakeholders to provide a seamless, timely referral system for CLC admission.
• Screens and reviews each referral for disposition and planning.
• Collaborates with both referring and accepting staff to ensure Veterans are placed in the program area that best meets their needs.
• Monitors bed availability and serves as the point of contact for the outcome of screening decisions.

Care Coordination & Transition Planning

• Follows the patient throughout their stay in the CLC.
• Assists with assessments, identification of barriers, and activities required to successfully transition patients into the CLC setting and post-discharge.
• Completes discharge planning and sets up home services as needed.
• Coordinates and collaborates with other VA and non-VA departments, community agencies, and healthcare providers to ensure patient needs are addressed.
• Initiates consultation for complex administrative and clinical issues.

Clinical Practice & Nursing Process

• Assesses, plans, implements, and evaluates care based on age-specific components.
• Applies the nursing process, which includes systematic data gathering, assessment, and appropriate nursing judgment to ensure positive patient outcomes.
• Administers medications and procedures per established policies and guidelines.
• Opens and completes the nursing sections of the Baseline and Comprehensive Care Plans.

RAI/MDS Assessment & Compliance

• Responsible for coding the nursing-assigned sections of the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Assessment and the Care Area Assessments (CAAs), adhering to current Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VHA) timeframes for assessment completion.
• Participates in Interdisciplinary Team care plan meetings, reviewing, communicating, and monitoring residents' care plans.
• Collaborates with the Resident Assessment Coordinator (RAC) to educate staff on the completion of the RAI/MDS process, including documentation requirements, MDS data entry, and software and program updates as needed.
• Documents and takes corrective action when notified by management of any discrepancies in coding or documentation of RAI/MDS assessments and CAAs reported during interrater reliability reviews.
• Serves as back-up for the RAC.

Quality Improvement & Survey Readiness

• Supports quality improvement activities.
• Participates in ongoing survey readiness activities.
• Collects and maintains data to enhance program planning and placement.
• Collaborates in the development, evaluation, and revision of policies, procedures, and/or guidelines.
• Responsible for documented outcomes at the program or service level.

Leadership & Professional Development

• Provides peers with formal or informal constructive feedback for improvement.
• Supports colleagues through knowledge sharing to provide safe, quality nursing care.
• Fosters an environment conducive to the professional development of health care professionals.
• Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations.

Additional Responsibilities

• Provides direct patient care as a Staff RN to support floor coverage as needed, ensuring continuity of safe, high-quality care for CLC residents.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards