Provide intense case management services to clients diagnose with a severe and persistent mental illness (Anxiety, Major Depression). Service severe clients in a mental health setting. Work with an interdisciplinary team of social workers, psychiatrists, primary care doctors, peers and nurses to provide services to the whole person.
Major Tasks, Duties and Responsibilities:
Note: The following statements reflect the general duties considered necessary in order to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the job.
- Provides field based nursing evaluations and monitors for changes in client’s health status; coordinates care with other health care providers on behalf of GART program.
- Educates clients and families about health care prevention services.
- Reviews medical reports and triages client needs.
- Accompanies clients to appointments with other health care providers, and follows up on appropriate referrals to address unmet health care needs.
- Develops relationships with Primary Care Clinics on behalf of GART clients.
- Develops required nursing procedures to ensure client health and safety.
- Participates in community health fairs, meetings, and interagency case conferences.
- Conducts visual assessments of the environmental conditions in the home of GART clients; conducts a baseline evaluation of the client’s medical and psycho-social needs.
- Assists GART staff in the development of treatment plans for GART clients per Quality Assurance standards of ACBHCS.
- Participates in staff meetings and reviews cases with other staff to maintain quality of care; works collaboratively with GART multi-disciplinary team..
- Provides feedback to the GART medical providers on the efficacy of medication prescribed to GART clients.
- Serves as an advocate for obtaining access to specialty care services, appointments, and referrals to other needed services.
- Participates in community outreach and health education activities that encourages utilization of preventive health services and development of healthy lifestyles.
- Serves as a consultant to community agencies, skilled nursing facilities, residential care facilities, and acute care settings in the area of older adult mental health conditions and/or co-occurring issues, recovery options, available services, behavioral management, and older adult issues.
- Develops competency in the area of older adult behavioral health care needs.
- Maintains all records in accordance with the Quality Assurance standards of ACBHCS.
- Performs other duties as assigned within the classification.