Team Nurse; RN

Adult Clinical Community Supports Team Nurse (Registered Nurse)

The Adult Clinical Community Supports (ACCS) Team Nurse (Registered Nurse) promotes the full integration and functioning of persons served (PS) needed to live a healthy life in the community. Utilizing a holistic, person-centered approach, the Team Nurse will coordinate access to and management of health care for PS. The Team Nurse will work in conjunction with Care Coordination entities and all associated medical and behavioral health providers.

Additionally, the Team Nurse will monitor and consult with team members regarding the medical and psychiatric conditions of PS. The Team Nurse will also develop the delivery of health promotion strategies for modifiable risk factors by the Team and oversee Medication Administration Program (MAP) compliance for Team and associated residential Group Living Environments and Supported Independent Environments.

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…