General Description

Responsible for providing an overview of all physical and behavioral health updates to ACT recipients. Promotes integrated medical and psychiatric care to ACT recipients in order to meet their individualized needs who experience severe mental health symptoms and may suffer from drug or alcohol dependencies.

Duties and Responsibilities

• Provides direct, face-to-face services and treatment to recipients from diverse backgrounds in the community (off-site) as needed based on recipients and/or family preferences.
• Responsible for providing guidance to the team in addressing all preventative, ongoing and critical health matters including nutritional or physical activity.
• Administers injections and educates participants on medication adherence.
• Collaborates with the Team Leader and Psychiatrist to monitor the ACT recipients’ psychiatric conditions and delivery of medications and observes any non-psychiatric conditions.
• Supports treatment to ACT recipients utilizing a recovery-oriented and person-centered approach.
• Provides appropriate community referrals such as medical doctors or primary care providers as necessary.
• Coordinates pharmacological services and delivery of medications to the ACT office of recipients home along with laboratory services for recipients as needed.
• Monitors, orders, and stores medical supplies.
• Implements and coordinates Wellness Self-Management Services and coaching techniques to create a personalized health plan.
• Performs physical assessments and basic health screenings and research new screening methods.
• Implements health action plans and other site-specific programs such as biometric screening, walking programs and other individuals who are at risk for diabetes, high blood pressure and high cholesterol and heart disease.
• Assist clients set and achieve meaningful goals in areas of diabetes, heart disease, weight management, nutritional guidance, stress management, wellness, and smoking cession.
• Provides health education to staff, providers, families, and significant others.
• Adheres to the medication administration procedures.
• Identifies behaviors that interfere with treatment and recovery and conducts suicide and violence risk assessments to decide if an increased level of care is needed by increased contacts by the ACT Team.
• Participates with ACT recipients to inclusively develop, implement, evaluate, and/or modify person-centered goals to foster quality of care and achieve the best possible outcomes.
• Attends the daily ACT team meetings and participates in regular treatment team meetings or case conferences to ensure the continuum of care for ACT recipients while they are on the road to recovery.
• Actively participates in the daily communication log.
• Stays informed of changes in the clinical status of recipients or stressors involving recipients’ life or/and their families/support systems.
• Provides clinical oversight and collaborates with team members to assess recipient needs to determine best practices. Promotes positive relationships within the Agency and other providers including inpatient hospital staff, pharmacy, insurance companies, community partners or service organizations etc., to ensure continuity of care.
• Creates and fosters inclusive and diverse external partnerships to support ACT recipients.
• Works collaboratively with the multi-disciplinary team in the provisions of all job duties.
• Fosters and models principles that underlie the ACT model (recovery, person-centered, cultural humility, continuous monitoring, and engagement efforts, accessible to a multi-disciplinary team)
• Participates and follows treatment requirements mandated under Assisted Outpatient Treatment (AOT) program including completing necessary documentation/evaluations
• Completes all required documentation including psychiatric and medical assessments, progress notes, treatment planning etc
• Provides guidance and ongoing education/training to staff members to foster an inclusive environment and demonstrates DEI concepts regarding individual cases.
• Recognizes emergency situations and takes appropriate action.
• Provides integrated treatment, rehabilitation, and support services to ACT recipients.
• Establishes evidence-based practices to reduce hospitalizations and homelessness.
• Serves as a liaison and attends meetings with external entities.