Uses the nursing process and evidence-based practice to collaborate with the Teamlet and larger Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. Provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. Follows the patient's personalized health care plan as designated by the patient and Patient Aligned Care Team (PACT). Promotes and provides patients with personalized, proactive, and patient-driven health care through such activities as assisting in developing a personal health plan, listening to the patient and addressing their needs/goals, engaging in group appointments, encouraging and supportin
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