Assertive Community Treatment Care Manager/RN
The Assertive Community Treatment Care Manager/RN is a professional position responsible for providing assertive, intensive community treatment services designed to prevent decompensation/hospitalization of adults, 18 years or older, with a severe and persistent mental illness.
The staff member will provide a range of services including assessments (including nursing assessments), treatment planning, supportive counseling, rehabilitative/skill building services, therapeutic services, medication management, emergency services, and case management activities such as: treatment planning, linking/coordinating, monitoring, and support.
The ACT Team provides Integrated Dual Disorder Services to eligible consumers of the ACT program and, as such, one member of the team will be designated as an IDDT Team Substance Abuse Specialist. The IDDT Team Substance Abuse Specialist must meet the criteria described in Appendix B of Policy 2.2.10 of the WMCMH Administrative Manual.
The position incumbent must be self-directed and function as a team player. The ACT Team works a flexible schedule, which may include evening, weekend, and holiday hours. Services will be provided in and out of the office. The staff member is required to provide ACT on-call emergency service as scheduled.
JOB DUTIES:
-
Program assessment and evaluation services
The process of completing a comprehensive assessment that determines service delivery eligibility, medical necessity, and therapeutic appropriateness and need for consumers seeking services at WMCMH. Assessments include diagnosis and functional impairments, service urgency and intensity, health and safety risks, specialized needs, desired service outcomes, the consumer’s strengths and assets, the support services most likely to be effective, and the availability of natural supports. This includes caseload-specific emergency screening, triage, and crisis containment services during normal business hours. -
Planning and/or facilitating planning using person-centered principles
The person-centered plan of service is produced by a coordinated effort by the staff member and the consumer in response to the assessment and describes the plan for delivering services to the consumer. The plan of service should include behaviorally defined and measurable objectives; person-centered service goals; interventions and supports that require consumer actions and identify scope, frequency, and duration; the use of available natural supports and specific discharge criteria. This also includes a crisis plan for the consumer. The plan will be periodically reviewed and amended with a re-assessment of the consumer’s progress, or lack thereof, in response to the plan of service goals, objectives, intervention/supports, discharge criteria, and the medical necessity for seeking the continuation of care. This may result in a change of level of care and/or episode of care discharge. -
Linking to, coordinating with, follow-up of, advocacy with, and /or monitoring Specialty Services and Supports, and other community services/supports
Connecting the consumer with all the appropriate resources, both internal and external, and coordinating care, services or benefits provided to the consumer. Coordinating services with the consumer’s personal care physician and the qualified health care providers. This also includes assisting the consumer in the development and maintenance of natural supports. -
Monitoring Services
Tracking of the consumer’s response to their individual person-centered plan of service and monitoring compliance and progress with all supports and services agreed to in the person- centered service plan. It is preferred that monitoring occurs when the consumer is present and engaged in the service process being monitored. Monitoring consumer medication in consultation with the Prescriber and/or staff nurse, ensuring the consumer is compliant with their medication intervention and monitoring potential side effects of the medications. -
Support Services
Acting as a consistent link into the system for the consumer and/or his family including educational support around the specific disability or mental health condition. Educating and/or counseling for families who are caring for, or who regularly interact with, a family member who has serious mental illness, severe emotional disturbance, or disability. Education includes information about the disability, treatment options and regimens, use of medication, management, and crisis situations, etc. -
Maintenance of the key elements of the individual consumer record
The clinical record is the responsibility of the care manager. The care manager is responsible to assure the record is up to date with releases, consents and obtaining clinical information. They are to assure that the consumer’s confidentiality of information is maintained, and the care manager is to have knowledge of what is in the clinical record. -
Mental Health Crisis Assessment and Intervention Services
Defined as the application of mental health crisis screening, crisis intervention and triage services during non-business hours for ACT consumers. -
Nursing Health Care Assessment, Intervention and Training Services
Includes the assessment, (the process to determine the recipients’ need for services and to recommend a course of treatment), healthcare intervention planning, (the development of Nursing Care Plans for consumers who have a development disability or a severe and persistent mental illness), and monitoring services, (the tracking of the consumer’s response to their individual nursing care plan, consultation/coordination with their care providers, and review of health history information with recommendations communicated to the agency care provider as required by agency protocols), and administration and/or review and monitoring of medication side effects for all age populations and disability groups.