The Patient-Centered Medical Home (PCMH) concept emphasizes team-based, comprehensive care that is designed to fully meet the complete primary care, health and wellness needs of patients across their life span. The PCMH team is a multidisciplinary primary care team which includes Physicians, Nurse Practitioners, Physician Assistants, Clinical Registered Nurses, Licensed Vocational/Practical Nurses, Hospital Corpsmen, Certified Medical Assistants, Medical Clerks, Embedded Pharmacists, Physical Therapists, Case Managers, Health Educators, Integrated Behavioral Mental Health Providers, and Disease and Population Health Managers. These health care professionals provide a patient-centered health care delivery approach that includes, but is not limited to, disease prevention, wellness, behavioral health, disease management, and force health readiness. The team is aligned to promote each member to utilize their full scope of practice or licensure. The incumbent may be assigned to a Family Medicine, Internal Medicine or Pediatric PCMH team, a Marine-Centered Medical Home, Fleet-Centered Medical Home, or other primary care clinic. This position is the Clinical Nurse for the PCMH team. The Clinical Nurse is an integral team member who provides complex nursing care to clinic patients that has a level of responsibility for the oversight of day-to-day team activities and care coordination of patients needs across the life span and continuum of care, provides guidance and direction to the teams licensed practical nurses and paraprofessional personnel, and contributes to all elements of a high reliable organization (HRO). MAJOR DUTIES AND RESPONSIBILITIES 1. Provides comprehensive and complex nursing care to clinic patients utilizing evidence- based approach and application of clinical practice guidelines. The incumbent utilizes evidence-based principles to make quality decisions for the provision of nursing care based upon personal clinical expertise in combination with the most current, relevant research available and participates in evidence-based practice and high reliability organization (HRO) initiatives to optimize patient outcomes. The incumbent provides comprehensive patient care that considers the physical, emotional, social, economic, and spiritual needs of the person, his or her response to illness, and the effect of the illness on the ability to meet self-care needs. The incumbent independently performs direct nursing care to clinic patients via telemedicine, virtual, and face-to-face care, to include care coordination and transition management, triage, invasive and non-invasive procedures, nurse led visits, and medication management. Invasive procedures performed include, but are not limited to, venipuncture, administration of intravenous fluids, medications, diagnostic and therapeutic agents, blood products, and pulmonary ventilation. Incumbent tracks patient's laboratory, radiology, and referral results to completion, and tracks and evaluates at-risk patients including, but not limited to, patients with condition and behavior arising from the use of new therapy or drugs by making and recording detailed comprehensive and accurate observations of patients physiological and emotional responses. Incumbent initiates and maintains medical history on patients, records observations, and stated symptoms for use by the clinician. Assists licensed practitioners in performing complicated physical examinations, treatments and diagnostic procedures. Interprets plans of care as well as provides patient and/or family health and wellness education. Incumbent applies approved protocols or algorithms when applicable to provide ease of access for patients. Performs assessments, identifies abnormalities, and provides nursing care and treatment for seriously ill or injured patients. Incumbent initiates emergency care as needed and assembles, operates, and monitors specialized equipment such as Electrocardiogram (ECG) machine, Nebulizer Spirometry, Pulse Oximeter machine, suction equipment and any other equipment used in the delivery of patient care. Ensures administrative requirements related to patients visit are completed timely and correctly. Utilizes automated programs and information technology as effective communication and management tools to facilitate the patient experience and coordination of care. 2. Proactively collaborates and integrates with members of the clinic team and other departments and directorates to achieve optimal care and health outcomes for the patients in the Patient-Centered Medical Home. Incumbent provides oversight and direction to nursing and ancillary support staff on their respective clinic teams within the assigned medical setting. Partners with the clinic manager and/or department head in directing, planning, coordinating, implementing, and evaluating activities related to the delivery of ambulatory nursing care. Participates actively in clinic team huddles; works closely with the team in the identification of needed population health measures and required procedures during schedule review; and reviews patients plan of care with team members for coordination. Acts as a patient advocate by facilitating communication for the patient with other departments and their staff as required. Maintains effective communication with staff, patients, families, and between other departments. Complies with and actively participates in all accreditation, certification, and/or PCMH recognition processes. Monitors teams compliance to environmental and life safety requirements and disaster/emergency preparedness procedures. Collaborates with other clinic team members in improving documentation of the episode of care using the Military Health System (MHS) and Navy Medicine approved standardized documentation templates in the Electronic Health Record (EHR) enabling measurement and analysis of nursing care, and linking patient complexity, nursing care needs, and nurse-sensitive outcomes. 3. Identifies clinical and administrative complications and independently utilizes problem solving techniques to ensure the delivery of quality patient care. Incumbent identifies new clinical and management requirements for the clinic and takes effective action to ensure necessary changes and adaptations are implemented. Incumbent precepts and mentors other team members to ensure competency in skills needed for optimal performance and collaborates with the clinic manager and/or other clinic leadership to identify lagging performance or competency among team staff and assists with re-training as required. Provides and participates in continuing education and training as appropriate for all levels of ancillary team staff and other nurses within assigned medical setting. Partners with the clinic manager and/or other clinic leadership to identify and address clinically related or process issues, or concerns as appropriate. If an emergency arises, incumbent independently takes appropriate action and supervises the delivery of emergency nursing care. Provides for orientation of new personnel; ensures duties of the clinic team commensurate with their abilities utilizing the orientation program. Assists in the development and revision of standard operating procedures governing clinic operations, utilization of virtual care resources, booking protocols, and other administrative functions such as end of day processing. Develops standards within the clinic directed at defining staff performance in ambulatory nursing activities. Leads and participates in periodic in-service programs for the continuing education of staff. Leads, manages and participates in quality improvement activities conducted within the clinic. Partners with clinic manager and/or department head in the day-to-day management of the clinical teams schedules, communicating any concerns with access to care or quality of care for the clinic teams patients. Coordinates schedules with other team members to ensure adequate access to care for the clinic teams patients. 4. The incumbent may be assigned additional duties and on-call watch bills based on staffing and command needs. Performs other duties as assigned.