Field Registered Nurse - ACT Program

About the role

As a member of the ACT team, the RN is responsible for providing a range of treatment to clients with a SPMI/SUD, rehabilitation and support services within the scope of the nursing practice for the clients receiving services from our ACT teams across the city. S/he is responsible for conducting initial nursing assessments and ongoing health monitoring assessments; assessing physical health needs; making appropriate referrals to community physicians as needed, providing medical case management and administration of medication in conjunction with the prescriptions/orders of psychiatrist, PNP, and medical providers. The majority of this role is conducted in the community and is not site specific. Each nurse will work with a primary program and may also work with other JB programs across the city. The RN will be supervised by the Program Director/Nursing leadership.

Responsibilities

• Carry a caseload and complete initial and ongoing nursing assessments.
• Conduct weekly visits thereafter for clients currently residing in homeless shelters and assigned to the ACT program and/or in client’s homes or elsewhere in the community where the client is accessible.
• Develop a treatment plan with the team, based on clients’ needs.
• Ensure that any medical diagnoses are addressed and the client will be educated as to conditions and signs and symptoms.
• Complete nursing assessments and health monitoring assessments within appropriate timeframes.
• Follow/implement all direction from Psychiatrist or PNP regarding medical treatments and medication orders.
• Administer prescribed and/or routine medical treatments, support clients and staff with self-administration of medication procedures and evaluate for potential side effects or adverse reactions.
• Ensure that all internal policies regarding such administration are adhered to.
• Partner with clients in a respectful, encouraging way to promote healthy lifestyle changes within a harm reduction framework, with shared decision‑making practices.
• Coordinate and deliver medications to the client’s residence or shelter, be responsible for medication counts, follow‑up with pharmacies (refills, insurance authorizations, etc.) and administer medication to clients.
• Make referrals, schedule appointments and accompany the client when required.
• Make visits to hospitalized clients to coordinate care.
• Provide advocacy for hospitalized clients.
• Assist with follow‑up care to promote complete recovery.
• Function as a liaison between external medical health care providers, shelters, other community organizations and the ACT team regarding the client’s medical needs.
• Responsible for health education and communicating information regarding good health practices to the clients under the RN’s care.
• Train staff in these practices to provide continuous health support to clients.
• Facilitate groups.
• Respond to medical emergencies as appropriate.
• Perform all necessary charting and other documentation as required by internal practice and external regulatory bodies within a timely manner.