POSITION OVERVIEW

Member of the BCORE team to provide clinically oriented outreach and engagement, clinical case coordination and therapeutic counseling for individuals who use or abuse opiates and other substances, diagnosed with a mental health disorder or dually diagnosed. Provide comprehensive and behavioral health care to a variety of patients in the community and coordinate health services between the Agency, community, and home/community settings. Responsible for conducting psychiatric assessments, assessing physical health needs including basic wound care, etc. In the community, coordinating all somatic appointments including referrals to necessary specialists, and assuring lab work ups are conducted as needed. Person will provide assistance and conduct medication management in coordination with team NP. Will also provide treatment, rehabilitation, and support services.

SPECIFIC RESPONSIBILITIES

• Engage clients in outdoor and public areas to develop rapport, monitor safety and health needs, connect clients to services, and support community members. 
• Earn and maintain clients’ trust through consistency, integrity, honesty, managing expectations, unconditional positive regard, and persistent follow-up; impart this approach throughout the team through role modeling, coaching, and close consultation. 
• Continuously seek new insights, options, and approaches to reach hard-to-engage clients with the philosophy that we never give up on anyone. 
• De-escalate crisis situations, help clients plan for and prevent crises, and seek assistance as appropriate. 
• Throughout the engagement process and upon enrollment, develop a comprehensive health history and needs assessment to understand clients’ priority needs.
• Evaluate and treat persons with complex social needs, addictions (such as opioid use disorder and polysubstance use disorder), serious mental illness, infectious disease (e.g. Hepatitis C, HIV, wounds related to drug use)
• Implement time-limited interventions to improve outcomes related to chronic health conditions (COPD, diabetes, heart disease).
• Formulate diagnostic impressions, implement clinical interventions within scope of practice, refer and coordinate care with external providers as needed, and collaborate with the outreach team on an overall plan of care. 
• Provide, develop, design, direct, and/or implement interventions to address client health needs.

• Evaluate clients upon admission to ACT; obtain complete psychiatric and medical health history.
• Formulate diagnostic impressions; develop and implement initial treatment plans, in collaboration with Nurse Practitioner by performing assessments, nursing diagnosis, planning, implementation and evaluation with regards to client care.
• Provide direct treatment, utilizing intensive or supportive individual, group, or family psychotherapy, psycho education or crisis intervention techniques as clinically indicated.
• Implement Psychiatrist assigned actions: sign off on necessary orders for non-nursing personnel.

• Instruct clients and families in regard to nutrition, medication, side effects, and all physical/psychiatric illnesses, dental care, substance abuse prevention, health maintenance and preventative care, including activities related to diagnostic testing preparation and prescribed treatment for acute and short-term treatment.
• Provide training in communicable disease prevention, prevention of sexually transmitted
• Provide case management for an assigned group of clients including coordinating and monitoring the activities of the individual treatment team; assume responsibility for developing, writing, implementing, evaluating, and revising overall treatment goals and plans in conjunction with the ITP; provide individual supportive counseling; assist in symptom management, ensuring immediate changes are made in the treatment plans as client’s needs change. Educate and support clients’ families and advocate for client rights and preferences.
• Conduct comprehensive assessment of all domains of a person’s life.

PRINCIPAL ACCOUNTABILITIES

Client evaluation, assessment, and ongoing treatment.

Client well-being (clinically and physically).

Monitor and document medication.

Direct community medical care, including wound care and harm reduction techniques

Education and training.

EDUCATION, WORK EXPERIENCE AND JOB REQUIREMENTS 

Education: Minimum of Registered Nurse license with two years’ experience and one year in area of specialization. Masters preferred.

Skill Requirement: One to six months On-the-Job-Training required for efficient job performance.

Job Requirements: Excellent communication, problem solving, and organizational skills.

Licensed as a Registered Nurse in the State of Maryland.

Must have a valid driver’s license and use of a personal car, as needed.

Must have a clean driving record.