Registered Nurse Home Based Primary Care (HBPC)

Department of Veterans Affairs • Jasper, AL

45d • Onsite

About The Position

The Home Based Primary Care (HBPC) Registered Nurse functions as a core member of the interdisciplinary team, providing comprehensive, continuous, and patient-centered care to Veterans with complex, chronic, or disabling conditions in their homes. The HBPC nurse plays a pivotal role in improving health outcomes, enhancing quality of life, and preventing unnecessary hospitalizations or nursing home placements. Duties include but not limited to:

Requirements

• 1 full and unrestricted license from any US State or territory

Nice To Haves

• Recent clinical nursing experience in community health, home health, medical-surgical, geriatrics, or primary care settings.
• Experience with comprehensive assessment, case management, and coordination of care for medically complex, high-risk, and homebound patients is preferred.
• Candidates should demonstrate strong clinical judgment, critical thinking, and communication skills, with the ability to work autonomously within an interdisciplinary team.
• Proficiency in electronic medical documentation, medication reconciliation, and patient and caregiver education is essential.
• Prior experience in a VA Home-Based Primary Care (HBPC) or similar interdisciplinary home care program is highly desirable.

Responsibilities

• Serves as the case manager for assigned Veterans enrolled in HBPC, coordinating care across disciplines including physicians, nurse practitioners, social workers, dietitians, therapists, and psychologists.
• Performs comprehensive assessments of physical, emotional, and psychosocial needs in the Veteran's home environment.
• Develops, implements, and regularly updates an individualized plan of care, ensuring it reflects Veteran and family goals, preferences, and changing clinical conditions.
• Provides direct nursing care, including medication management, wound care, chronic disease management, and health education.
• Collaborates with the interdisciplinary treatment team during regular IDT meetings to review care plans, adjust treatment goals, and coordinate services.
• Promotes patient and caregiver self-management of chronic illness through teaching, coaching, and ongoing support.
• Documents all encounters, assessments, interventions, and communications in the electronic health record (CPRS) timely and accurately, ensuring compliance with VA documentation standards.
• Identifies and addresses environmental and safety risks in the home, initiating appropriate interventions or referrals.
• Acts as a liaison between the Veteran, family, and VA/non-VA care providers, ensuring smooth transitions of care and continuity of services.
• Participates in performance improvement activities, program evaluation, and implementation of evidence-based practice to enhance HBPC outcomes.
• Ensures compliance with all VA policies, Joint Commission standards, and other regulatory requirements governing home care services.

Benefits

• Competitive salary, regular salary increases, potential for performance awards
• 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Administration of Human Resource Programs
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees