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Overview: The Registered Nurse is a member of the Nathaniel Clinic staff providing clinical care to clients in the area of integration of primary care services and outpatient mental health services within the clinic. The integrated services are being implemented by CASES and our partners the Institute of Family Health (IFH). The RN will direct the treatment and clinical care of the clients for the SAMHSA Primary Care Behavioral Health Integration (PCBHI) grant delivering integrated services to adults with serious mental illness. This position requires hands on clinical skills with understanding of clients conditions that suffer from serious mental health issues and/or diagnoses. The RN will develop integrated clinical workflows and clinical registries to facilitate an agency-wide cultural shift towards integration and shared accountability for consumers' whole health. The RN must have relentless commitment to shared treatment planning and shared decision-making between mental health and primary care staff. The RN must be competent in the effective use of health information technology (HIT) and data to manage and improve the quality of care. The goal of the Nathaniel Clinic is to offer mental health treatment in Central Harlem to criminal justice involved youth and adults. Mission driven candidates committed to social justice and the goal of increasing public safety through innovative services that reduce crime and incarceration and improve health will be ideally suited for this position.
• Perform initial health monitoring assessments and develop wellness care plan for ongoing monitoring visits not excluding performing diagnostics such as lab draw and/or administering injections while counseling education as well as provide any care coordination for referrals and prescriptions as needed
• Engaged closely with psychotherapists and scheduling staff to ensure admissions are scheduled for initial health monitoring visits
• Enroll clients into wellness program and national outcomes measurement system as applicable
• Daily review of diagnostic results including laboratory studies for critical values and address appropriately
• Work with the CASES employees on the PCBHI team and work closely in collaboration with the IFH provider (FNP/MD) to provide clinical updates around the team's integration into the Nathaniel Clinic's operations and services for consumers receiving outpatient services
• Participate in organizational, weekly multidisciplinary meetings and case conferences with all providers (MH, primary care, pharmacy, care managers, housing providers, and
criminal justice providers) serving consumers for joint treatment planning, shared decision-making, and complex care review
• May provide psychotherapy, initial comprehensive assessments, and complex care management to a small caseload of PCBHI consumers
• Ensure evidence-based practices, Wellness Self-Management Plus, smoking cessation and weight loss services are effectively implemented.
• Maintain all quality, compliance, utilization review and regulatory controls to ensure appropriate and high-quality services, in consultation with Nathaniel Clinic Director, IFH leadership and providers, consumer representatives, advisory group, Evaluator, Managed Care Organizations and Health Homes.
• Review clients records for annual physical review and health monitoring progress as well as ensure the quality and timeliness of clinical documentation in accordance with CASES and IFH standards
• Collaborate with external evaluator and ensure integrity and quality of program data
• Routinely use data including PSYCKES quality health indicators, Managed Care Organization (MCO) data, and program level data to monitor, track, and analyze the effectiveness and cost of services.
• Ensure PCBHI consumers are engaged in Health Home care management.
• Assist team members through individual and group conferences in analyzing case problems, improving services and consumer outcomes.
• Ensure appropriate team follow-up and discharge coordination following consumer ER visits and inpatient stays.
• Recommend policies and procedures to promote integrated care within the Nathaniel Clinic and for ACT consumers.
• Interface with IFH leadership, and CASES' quality assurance, corporate compliance, EHR, strategic planning & analysis, fiscal/business staff to ensure services are effectively implemented and are sustained.
• Support PCBHI sustainability activities with active participation in evaluation, outreach, engagement, and presentations to MCOs, Delivery System Reform Incentive Program (DSRIP) Performing Provider Systems, NYS and NYC mental health and health agencies, and Health Homes.
• Provide 24-hour emergency and crisis intervention rotating phone coverage.
• Order medical supplies as needed and perform monthly exam room checks.
• Provide culturally competent services in accordance with CASES policies.
• Any other duties as required by supervisory and directors.
• Registered Nurse (RN)
• At least one year experience working with adults with serious mental illness and co-occurring substance use disorders
• Proficient in behavioral health and primary care integration models
• Ability to work effectively with diverse team and remain highly organized
Posted on 12/20/18; CVMHA ID #12560