CTT is mandated to provide services to those individuals within the mental health system who presents the greatest degree of severity of symptomatology as evidence by their multiple physical, psychiatric, and legal conditions, extensive use of services, and lack of follow through with treatment. This population requires the highest level of medical necessity as defined by the state Adult Environmental Matrix.
As a member of the ACT multidisciplinary team is responsible for conducting psychiatric assessments; assessing physical health needs; making appropriate referrals to community physicians; providing management and administration of medication in conjunction with the psychiatrist; providing of range of treatment, rehabilitation, and support services; and sharing shift management responsibility with other staff.
As a member of an ACT team, the CTT nurse provides an array of health care support to consumers, other team members and services providers. Utilizing the Community Support Program model, the CTT Nurse routinely assessed the psychiatric and physical health care needs of these persons. The incumbent developed a strength-oriented treatment/service plan that addresses consumer health care needs through the identification and utilization of community resources.
The nurse is responsible to ensure that the mission, goals and philosophy of CTT are operationalized within the team, especially as they apply to health care services. Provide care appropriate to the age and ethnic/cultural background of the consumer.
The incumbent works with staff to ensure continuity of care, and enhancement of consumer understanding, acquisition and maintenance of independence living skills in the area of: (a) their daily living situation ;(b) interpersonal skills and social support/network building; (c) leisure and recreational support/skills development; (d) maintained and enhancement of physical and mental needs.
One hundred percent (100%) of the incumbent's contacts are billable services.
Duties and Responsibilities:
Coordinates the health care needs of assigned consumers: Utilizes professional expertise, theory, and practice as a basis for assessing, planning, implementing, and evaluating psychiatric and medical needs of consumers according to ACT policy and guidelines in the community
Maintain records of medical history and on going medical records. Complete Nursing Health Assessment for CTT consumers: annually and updated as needed, including initial nutritional assessment and on-going nutritional information and education. Develop and implement individualized health treatment plans.
Provide comprehensive service coordination (Case Management) to assigned consumers per policies according to ACT program standards. Consult with Team regarding development and implications of Nursing and Service Plan, Develops comprehensive treatment plans according ACT program standards utilizing behaviorally specific language, specific interventions, and measurable goals, individually tailored to the specific consumers’ needs.
Negotiate the health care responsibilities of each consumer with provider agencies and CTT. Facilitate the use of generic services.
Participate on assigned teams providing expertise in the area of physical health and in daily staff organizational meetings and treatment planning review meetings. Coordination with team members’ consumers’ routine medical, vision, lab, and dental appointments. Use protocols for reporting of results and follow-up.
Accompany consumers to an appointment when it is determine necessary by the nurse, and the team.
Attend psychiatric team meetings to review medication, Personal Plans and response to treatment.
Attend team meetings to review the health care needs, consumers’ response to treatment and coordinate the scheduling of the scheduling of appointments.
Take the lead role and/or participate in providing medications. Monitor and administer consumer medications. Coordinate and as necessary administer injections.
Participate in discharge planning for consumers from acute or extended care facilities.
Monitor and, as necessary, provide medical treatment in the community as prescribed by a recognized medical service vendor.
Complete appropriate documentation:
Develop, review, and revise forms, procedures, and standards of care according to accepted National Standards of Nursing Practice Act.
Document service provided according to CTT policy. Complete Service Documentation as required for all consumers related activities (billable).
Service as a member of the CTT Quality Assessment program.
Maintain and update nurses' section(s) of the consumer Personal Records according to CTT policy and procedures standards.
Complete medication administration records (MAR) PO and Intramuscular injection (IM) records according to CTT policy and procedures standards.
Monitor status of consumer in acute hospital setting.
Provides consultation services.
Services are provided to community agencies upon request when it is determined by CTT and nurses that it is required.
Services are provided to teams at regular scheduled team meetings and upon request of a team member.
Community services are provided upon request in consultation with the Clinical Director.
Provide Educational and Training.
Educational and training sessions are conducted with consumers, families, providers’ agencies and CTT Staff. Utilize effective communication skills to communicate with consumers, family members, and team members, to ensure that consumers’ needs are met.
Subject matter and prescription is based upon individual and group needs. Training to meet Accrediting Body standards is also provided.
Performes others duties as required
Must have excellent verbal and written communication skills. Ability to work well with people, have creative problem solving skills. Present current clinical skills; knowledge of mental health system/ community resources networking skills; ability to work independently, flexible and adaptive in handling changing priorities in a fast pace work environment and able to work extended hours as may be required.
Educational and Experience:
Registered Nurses Degree with at least two (2) years experience in the mental health field. Pennsylvania Licensed in good standing.
Ability to sit for at least one hour at a time, and to use a telephone. Able to climb stairs at consumers residences, bend, stoop, push, and pull file drawers, and lift up to 20lbs. must have excellent verbal and written communication skills. Ability to work well with people, have creative problem solving skills. Present current clinical skills; knowledge of mental health system/ community resources networking skills; ability to work independently, flexible and adaptive in handling changing priorities in a fast pace work environment and able to work extended hours as may be required.
Other Job Requirements:
Must have a valid driver's license, auto insurance and vehicle for job related travel in the community; ability to work in a team environment and share office space; ability to work evenings and weekends in meeting on call responsibilities.