The Fayetteville Health Care Center's Clinical Geriatric Care Coordinator is responsible for proactively providing Geriatric Care Coordination to prevent unnecessary nursing home care by identifying High Risk Veterans through the use of predictive analytic tools. Identifies Veterans who would benefit from support coordination for early intervention and comprehensive review of service available to support Veteran's needs that are available within the VA and from community partners. The Clinical Geriatric Care Coordinator administers information and analytical systems to evaluate and enhance the quality of service provided to Veterans Develops and implements information systems to track service activities including visits, referrals, inpatient days, patient demographics, equipment utilization and patient satisfaction Develops, implements, and evaluates clinical guidelines and protocols to establish appropriate utilization of services and referral to Non-Instructional Care Programs Contracts and establishes a continuing relationship with the Veteran, evaluating progress towards goals and adjusting the treatment plan as appropriate Meets with the Veteran to assess accomplishments and re-establish goals as needed Makes recommendations for care and changes to interdisciplinary treatment plan Documents independently in the medical records utilizing paper and/or electronic formats, including psychosocial assessments, diagnostics, treatment, progress notes, follow-up and referral Manages the quality control and evaluation of the professional services provided Devises methods of obtaining data and evaluates data to determine the effectiveness of treatment Identifies consistent qualities of successful treatment and of failed treatment Directs/coordinates clinical and psychosocial services and is accountable for the overall effectiveness of the service provided Modifies services to best meet the treatment needs of Veterans and to promote efficient practice Coordinates social work services with other services offered in the treatment program, assuring such services are complementary and comprehensive Interviews Veterans and their family members/significant others to establish facts about the Veteran's situation, presenting problems and their causes, and the impact of such problems on the Veteran's functioning and health as part of a comprehensive psychosocial assessment, and focuses on the patient in the context of family and community by integrating an assessment of living conditions, individual and family dynamics, and cultural background into the patient's plan of care Interprets and explains VA's treatment and benefit programs Reviews all data, subjective and objective, and makes a clinical assessment, identifying needs and strengths; effectively using professional skill, objectivity and insight Uses advanced clinical training, insight and experience to interpret data and to identify viable treatment options Assess high risk factors, acuity and need for services Possesses the ability to serve Veterans who have serious, frequent medical crises, lack of adequate family or community support network, have limited financial resources, are poor at self-monitoring, frequently fail to comply with instructions and treatment, have significant deficits in coping skills and require continuing professional traumatic physical disabilities Independently evaluates the client's situation, including the Veteran's reaction and arrives at a reasoned conclusion Based on the psychosocial assessment, uses professional judgment and advanced practice skills to make a psychosocial diagnosis Assesses at-risk factors and develops a preliminary disposition plan, involving the Veteran and family or signification others Performs insightful assessments of serious and complicated cases involving psychiatric illness, catastrophic medical conditions, dementia and other high-risk diagnoses Develops psychosocial treatment plans in coordination with interdisciplinary team members, including goals for psychosocial treatment Possesses knowledge of the vast array of VA, federal, stat and local community agencies and resources Possesses knowledge of terminal illness and end of life planning processes Makes adjustments to psychosocial treatment plans and interventions based on changing needs and response to interventions Communicates confidence in the Veteran's ability and worth, helping the Veteran address problems utilizing larger support systems as appropriate Consults with other Specialists in planning treatment for Veterans with co-morbidities Provides a wide range of services and technical assistance to state, local, and private agencies, and universities Performs program analysis, development, review, research, design, and contact work, as possible, with various agencies (public, DOD, state, etc) Possesses the ability to manage conflict and utilize negotiation skills in order to maintain productive work relationships with other disciplines in delineation of roles, and adapting a team approach to providing effective care of patients Coordinates staffing, work assignments, budget, treatment services provided, and admission criteria for the program Provides leadership, direction, orientation, in-service training and continuing education programs for assigned and other VA staff Work Schedule: 8:00am - 4:30pm, Monday - Friday Financial Disclosure Report: Not required
Internal Number: 600184700
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.