Team Nurse (RN)

About the role

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

• 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.
• Model appropriate interventions for direct service staff.
• 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.
• Oversee MAP policies, protocols, audits and compliance for Team and associated GLEs and SIEs.
• Maintain accurate and thorough documentation of PS needs and services.
• Obtain and review all 485s from VNA services and obtain updates on a regular basis.
• 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.
• 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.
• 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.

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.

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.
• Ability 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.
• 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.

Additional Certifications Required

• CPR required within first two weeks of hire.

Pay Range

USD $87,000.00 - USD $87,000.00 /Yr.