Key Responsibilities:
Manage and provide comprehensive advanced nursing practice for targeted patient
populations
Evaluate patient responses to therapy/interventions
Deliver thorough advanced nursing care including physical examinations
comprehensive history assessments screenings for physical and/or psychological
conditions emergent interventions pharmacological and nonpharmacological
interventions treatment and DME orders preventative health maintenance activities care
management referrals discharge planning counseling and patient education
Develop treatment plans based on clinical findings and determine the need for further
evaluation by collaborating physicians specialists or emergency care when warranted
Assess educate and enhance client and caregiver knowledge of chronic diseases self
care management and identification of changes in health status through individualized
education and interprofessional interventions
Observe and analyze team performance patterns related to the assigned population and
contribute to the development of interventions to improve team performance
Identify staffing needs for the assigned population and recommend changes as needed
Communicate effectively with internal and external care partners to ensure timely and
appropriate interventions for patient needs
Participate in the VNS Health Medical Care at Home Quality and Professional Advisory
Committee contributing to the development of evidencebased clinical models of care
peer education and training quality improvement medical record configuration and
reporting and maximizing the use of clinical decision support systems
Participate in grant application writing and presentations to internal and external groups
as assigned
Act as a preceptor for students of all disciplines offering exemplary role modeling of
communitybased primary care practice
Take responsibility for continued professional growth maintaining professional
certification and licensure
Function as a leader and supporter of shared governance participating in Magnet
councils as a subject matter expert
Perform supervisory duties as required.