Overview
The ACCS Team Nurse (Registered Nurse) promotes the full integration and functioning of Persons Served (PS) needed to live a healthy life in the community. Coordinates access to and management of health care for PS in conjunction with Care Coordination entities and all associated medical and behavioral health providers. Monitors and consults with team members regarding the medical and psychiatric conditions of PS. Develops and oversees the delivery of health promotion strategies for modifiable risk factors by the Team. Oversees Medication Administration Program (MAP) compliance for
Team and associated GLEs and SIEs.
Responsibilities
The essential job duties/responsibilities of the position include but are not limited to the information listed below:
• Meet with and conduct assessment of physical health of each PS served by the Team annually. Update assessment when significant medical status changes occur.
• Educate and train direct service staff on pertinent health matters regarding PS condition, diagnosis(s), medication and signs and symptoms of chronic, acute and urgent physical health issues (e.g. Diabetes, HTN, CHF, COPD, Vital signs management).
• Consult with team members on medical and nursing needs of PS.
• Participate as member of intervention team for assigned PS.
• Monitor and communicate PS needs for, and coordinate PS access to, health care with Care
Coordination entities and all associated medical and behavioral health providers as needed.
• Facilitate referrals to community providers as needed with Care Coordination entities.
• Attend hospital discharge meetings when significant medical issues are present, advocate for rehabilitative stay if needed, and obtain hospital discharge summaries at time of discharge.
• Educate and support PS families and friends (following HIPAA authorization protocols) regarding PS needs and preferences as they relate to health care.
• Complete Nursing and Health Assessments in the community for PS as assigned.
• Engage PS in personal health promotion activities targeted at modifiable risk factors. Use recovery-oriented, person-centered, motivational interviewing, harm-reduction, trauma-informed, culturally competent, and strengths-based approaches to help PS think through their current health circumstances, consequences and interest in change.
• Design, facilitate and oversee health promotion interventions to address modifiable risk factors for early morbidity and mortality of PS; including those served by both Team and those residing in GLEs/SIEs. Model appropriate interventions for direct service staff.
• Design, facilitate and oversee health promotion interventions to address overall health and wellbeing of PS.
• Monitor medical and psychiatric conditions of PS. Record relevant information following established protocols.
• Oversee MAP policies, protocols, audits and compliance for Team and associated GLEs and SIEs. Ensure that medications for PS are stored, administered, and disposed of in accordance with MAP requirements and company policies.
• Train/tutor staff to prepare for MAP certification and recertification. Teach MAP at least once per year. Attend State mandated MAP Consultant meetings twice a year.
• Monitor receipt of physical, dental and other medical documentation; work with Care Coordination entities and care providers to obtain as needed. Provide thorough and thoughtful documentation of PS needs and services.
• When a PS is authorized for Home Health and/or Personal Care Attendant (PCA) services, obtain and review all 485s from VNA services and obtain updates on a regular basis. Consult with VNA primary care nurse regularly.
• Advocate with medical providers for simple, effective medication regimens and for the reduction of poly-pharmacy.
• May provide outreach services as needed to PS when they appear to disengage from ACCS services.
• Promote employment services access for PS.
• Perform, mentor, model evidenced-based clinical and recovery oriented interventions for PS, including Motivational Interviewing; Harm Reduction and Addiction Treatment support; Screening; Brief Intervention, Referral and Treatment (SBIRT); Housing First; Stages of Change; Wellness Recovery Action Plans (WRAP); Seeking Safety and Cognitive Behavioral interventions.
• Promote engagement, safe housing, community tenure, achievement of greater self-sufficiency and successful completion of service for all PS.
• Provide on-call clinical coverage as scheduled.
• Engage as Member of ACCS Nurse Community of Practice, facilitated by Vinfen's Director of Nursing, to support and improve role competency and professional development.
• May serve, on a limited basis, as LPHA for PS with identified high risk medical needs to facilitate Care Coordination with external parties.
• Perform other related duties, as assigned.
Knowledge and Skills:
• Strong commitment to the right and ability of people served by ACCS to live, work, have meaningful relationships and receive the clinical treatment, resources and supports needed to thrive in their community of choice
• Knowledge of Nursing treatment principles and modalities, best practices and evidence-based practices
• Knowledge of health risks of psychiatric disability
• Ability to adhere to the standards of Motivational Interviewing; Harm Reduction; Screening, Brief Intervention, Referral and Treatment (SBIRT); Housing First; Stages of Change; and Cognitive Behavioral interventions
• Knowledge of PS engagement strategies
• Knowledge of medical crisis prevention, crisis intervention, and risk management strategies
• Knowledge of recovery-oriented, person-centered and strengths-based values and principles
• Knowledge of trauma-informed and culturally competent services. Sensitivity to the cultural, religious, ethnic, disability and gender issues of PS
• Knowledge of the effects of prejudice including internalized negative attitudes about oneself, discrimination, and oppression of people with psychiatric disorders, and effects of poverty.
• Knowledge of human, legal, and civil rights of PS
• Knowledge of medical and psychiatric emergency services and acute care systems
• Knowledge of community based mental health, health care, care coordination and other services and resources available to PS
• Skills and competence to formulate effective Treatment Plan interventions, and to train paraprofessional staff to implement aspects of plans
• Ability to collaborate effectively with other Team members to address the needs of PS in the Treatment Plan
• Ability to form supportive, trusting relationships with PS
• Knowledge of Nursing assessment practices
• Knowledge and use of different communication and learning styles
• Ability to make independent judgments and decisions
• Ability to work in a professional and confidential capacity
• Knowledge of personal computer applications and equipment
• Extensive knowledge of documentation standards and requirements
Qualifications
Typical Requirements:
• Nursing school education and training required. Bachelor's degree preferred.
• Registered Nurse in Massachusetts required.
• Three to five years supervised practical experience preferred, including internships.
• Experience working with people with psychiatric disability and/or co-occurring disorders preferred.
• Must have access to an operational and insured vehicle and be willing to use it to transport PS.
• Bilingual/bicultural applicants and applicants with lived experience of psychiatric conditions are encouraged to apply.
Driving Requirements:
Driving is a requirement for this position using either a Vinfen van or a personal vehicle. If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least six monthsr, and must be able to pass a driver's screening background check.
Physical Effort:
Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position.
Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift.
Ability to operate a computer and other office equipment such as a calculator, copier, and printer.
Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways.
Ability to assist PS with tasks of daily living.
Ability to remain in a stationary position 50% of the time as needed.
Ability to bend, reach, file, sit, stand, and move around the facility.
Ability to speak, hear, and communicate with PS, staff, and external representatives.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
Additional Certifications Required:
CPR required within first two weeks of hire
Pay Range
USD $89,175.00 - USD $89,175.00 /Yr.
