GeriPsych Senior Outreach Coordinator

Senior Mental Health Outreach services are designed to prevent or reduce psychiatric hospitalization by improving access to mental health services for older adults/ adults with disabilities who are unable to access mental health services within traditional treatment settings. This program can also reduce the risk of nursing facility admissions for Older Adults/ Adults with disabilities by improving access to information

and resources related to behavioral health services and other supports needed to remain in the community. The RN will provide assertive outreach, consumer engagement, behavioral health screening and assessment, and linkage to behavioral health and other community services for individuals referred aged 65 and over in their homes.

The ideal candidate for this position should have:

• Field work and an active driver's license.
• Case Management experience
• BSN
• 1 year minimum of Nursing licensure and experience

Clinical Practice/Care Delivery

• Competent in care of practice setting specific patient population; independently practices with solid knowledge and clinical skills; engaged in advancing own practice
• Collaborates with interdisciplinary team to plan and coordinate care addressing patient/family needs
• Provides direct and indirect care in area of specialization to patients and families, and objectively and systematically evaluates the quality and appropriateness of care delivery.
• Serves a clinical resource to others
• Serves as an effective Primary Coordinating Nurse; collaborates and coordinates with physicians and all disciplines involved in the patient’s care to assure timely progress toward the best clinical outcome in the most cost-effective manner.
• Provides symptom management strategies to a defined patient population in collaboration with physician.
• Utilizes and integrates evidence into practice
• Triages patient telephone inquiries and provides consultations as needed.
• Provides extensive patient education regarding disease process, treatment plan, and symptom management. Expertise in specialty area enables nurse coordinator to triage and assess patients in order to provide optimum level of care. Assists patients and families through disease process and along the care continuum.
• Ensures development and implementation of effective discharge plans and concurrently and retrospectively reviews patients for medical appropriateness and risk management issues.
• Assists patients with authorizing and pre-certification of insurance coverage for tests as ordered as part of the treatment plan.
• Active participant in Clinical Practice governance activities

Practice focus Areas:

• Develops patient education materials and overall process for practice setting-based patient education

• Assists in the development of clinical practice protocols and standards

Professional Development

• Responsible for maintaining competencies required for the patient care setting; focus on advancing own professional development
• Attends educational offerings and in-services independently
• Serves as preceptor, coach, mentor to new nurses, students
• Contributes to ancillary personnel skills and development
• Fosters educational development of self and staff and promotes the development of a multi-disciplinary patient care philosophy at UMMC.

Practice focus Areas:

• Active participant in Professional Development governance activities
• Contributes to practice setting-based education and learning activities (2/year that could be posters, storyboards, presentation, in-service, group project)
• Assists with developing/evaluating practice setting-based orientation program
• Serves as Super-user or assists in competency validation
• Provides health-related contributions through community services, such as health fairs

Service Quality/Safety

• Models customer service behaviors; supports “Best Practices” for customer service; learning service recovery skills
• Participates in some or all elements of research
• Manages/coordinates activities designed to improve performance in assigned programs. Participates in practice setting based PI efforts; assists in development of action plans and supports implementation
• Participates in implementation efforts addressing NSQI. Reports the status of progress and recommends/implements appropriate measures for Performance Improvement (PI).
• Actively endorses evidence based practice; participates in practice setting based research

Practice focus Areas:

• Active participant in clinic based Process Improvement activities
• Collects patient/family satisfaction data; assists with tracking and developing action plans for improvement
• Participates in collection of data related to outcomes, e.g. hand offs, medication safety, etc
• Participates in practice setting based research activities and/or research council or team
• Assists with TJC readiness

Unit Operations

• Serves to problem solve; focusing on operational issues that may impede patient outcomes in a timely manner.
• Participates in teambuilding efforts on the practice setting; supports and models teamwork
• Fully participates in nursing governance
• Accountable for compliance with regulatory requirements and holds others accountable
• Participates and supports the AACN guidelines for Healthy Work Environment (communication, collaboration, effective decision making, recognition, leadership, staffing)

Practice focus Areas:

• Participates in practice setting-based Reward and Recognition activities
• Leads efforts that support practice setting operations such as equipment maintenance, scheduling, etc.
• Orients nurses to governance structure and councils
• Contributes to development of ambulatory-based peer review processes; actively participates in individual peer review feedback
• Identifies areas impacting practice setting operations and assists in developing/implementing action plans
• Participates as member of a team focusing on elements within the Healthy Work Environment

Clinical Practice/Care Delivery

• Competent in care of practice setting specific patient population; independently practices with solid knowledge and clinical skills; engaged in advancing own practice
• Collaborates with interdisciplinary team to plan and coordinate care addressing patient/family needs
• Provides direct and indirect care in area of specialization to patients and families, and objectively and systematically evaluates the quality and appropriateness of care delivery.
• Serves a clinical resource to others
• Serves as an effective Primary Coordinating Nurse; collaborates and coordinates with physicians and all disciplines involved in the patient’s care to assure timely progress toward the best clinical outcome in the most cost effective manner.
• Provides symptom management strategies to a defined patient population in collaboration with physician.
• Utilizes and integrates evidence into practice
• Triages patient telephone inquiries and provides consultations as needed.
• Provides extensive patient education regarding disease process, treatment plan, and symptom management. Expertise in specialty area enables nurse coordinator to triage and assess patients in order to provide optimum level of care. Assists patients and families through disease process and along the care continuum.
• Ensures development and implementation of effective discharge plans and concurrently and retrospectively reviews patients for medical appropriateness and risk management issues.
• Assists patients with authorizing and pre-certification of insurance coverage for tests as ordered as part of the treatment plan.
• Active participant in Clinical Practice governance activities

Practice focus Areas:

• Develops patient education materials and overall process for practice setting-based patient education

• Assists in the development of clinical practice protocols and standards

Professional Development

• Responsible for maintaining competencies required for the patient care setting; focus on advancing own professional development
• Attends educational offerings and in-services independently
• Serves as preceptor, coach, mentor to new nurses, students
• Contributes to ancillary personnel skills and development
• Fosters educational development of self and staff and promotes the development of a multi-disciplinary patient care philosophy at UMMC.

Practice focus Areas:

• Active participant in Professional Development governance activities
• Contributes to practice setting-based education and learning activities (2/year that could be posters, storyboards, presentation, in-service, group project)
• Assists with developing/evaluating practice setting-based orientation program
• Serves as Super-user or assists in competency validation
• Provides health-related contributions through community services, such as health fairs

Service Quality/Safety

• Models customer service behaviors; supports “Best Practices” for customer service; learning service recovery skills
• Participates in some or all elements of research
• Manages/coordinates activities designed to improve performance in assigned programs. Participates in practice setting based PI efforts; assists in development of action plans and supports implementation
• Participates in implementation efforts addressing NSQI. Reports the status of progress and recommends/implements appropriate measures for Performance Improvement (PI).
• Actively endorses evidence based practice; participates in practice setting based research

Practice focus Areas:

• Active participant in clinic based Process Improvement activities
• Collects patient/family satisfaction data; assists with tracking and developing action plans for improvement
• Participates in collection of data related to outcomes, e.g. hand offs, medication safety, etc
• Participates in practice setting based research activities and/or research council or team
• Assists with TJC readiness

Unit Operations

• Serves to problem solve; focusing on operational issues that may impede patient outcomes in a timely manner.
• Participates in teambuilding efforts on the practice setting; supports and models teamwork
• Fully participates in nursing governance
• Accountable for compliance with regulatory requirements and holds others accountable
• Participates and supports the AACN guidelines for Healthy Work Environment (communication, collaboration, effective decision making, recognition, leadership, staffing)

Practice focus Areas:

• Participates in practice setting-based Reward and Recognition activities
• Leads efforts that support practice setting operations such as equipment maintenance, scheduling, etc.
• Orients nurses to governance structure and councils
• Contributes to development of ambulatory-based peer review processes; actively participates in individual peer review feedback
• Identifies areas impacting practice setting operations and assists in developing/implementing action plans
• Participates as member of a team focusing on elements within the Healthy Work Environment