Summary
This member if the ACT multidisciplinary team has training in one of the mental health professions (e.g., nursing, social work, rehabilitation counseling, or psychology) and clinical skill and experience to assess, plan, develop, coordinate, and provide treatment, rehabilitation, and support services to program clients with severe and persistent mental illness under the clinical supervision of the team leader and the psychiatrist. Functions as a clinical member of the multidisciplinary team and provides treatment, rehabilitation, and support services or may be designated by the team leader to function as the lead mental health professional, lead registered nurse, a team vocational specialist, or substance use specialist.
Principles Duties and Responsibilities
Provide service coordination (case management) for an assigned group of clients including coordinating and monitoring the activities of the individual treatment team; assume primary responsibility for developing, writing, implementing, evaluating and revising overall treatment goals and plans in collaboration with the client; provide individual supportive therapy, psychotherapy, and symptom management, ensuring immediate changes are made in the treatment plans a clients’ needs change; educate and support clients’ families, and advocate for clients’ rights and preferences.
Conduct comprehensive assessment of psychiatric history (e.g., onset, course and effect of illness, past treatment and responses, and risk behaviors), mental status, and diagnosis; physical health and dental health; use of drugs or alcohol; education and employment; social development and functioning; activities of daily living (e.g., self-care, living situation, nutrition, money management); and family structure and relationships.
Acts as liaison and consult with community agencies and families to maintain coordination in the treatment process.
Perform shift management in coordination with other ACT shift managers according to established policies and procedures.
Provide on-call crisis intervention covering nighttime hours and serve as a backup to evening and weekend staff.
Document clients progress to maintain a permanent record of client activity according to established methods and procedures.
Provide treatment, rehabilitation, and support services, with some interventions directed or performed by staff with specialty training and skills (e.g., vocational specialist).
Take lead role or participate in providing substance use and treatment services.
Psychiatric Treatment and Dual Diagnosis Substance Abuse Services
Provide ongoing assessments of clients’ mental illness symptoms and clients’ response to treatment. Make appropriate changes in treatment plans to ensure immediate and appropriate interventions are provided in response to changes in mental status or behavior which puts clients at risk (e.g., suicidal).
Provide symptom education to enable clients to identify their mental illness symptoms.
Provide direct clinical services including individual supportive therapy and psychotherapy to clients on an individual, group, and family basis in the office and in the community settings to teach behavioral symptom-management techniques to alleviate and manage symptoms not reduced with medication and to promote personal growth and development by assisting clients to adapt to and cope with internal and external stresses.
Provide individual and group treatment in the office and in community settings in a stage-based treatment model that is non-confrontational, considers interaction of mental illness and substance abuse, and has client-determined goals.
Coordinate with outside inpatient services to detoxify clients and establish linkage to outpatient treatment, self-help programs (e.g., Alcoholics Anonymous, Narcotics Anonymous), outpatient services, and residential facilities.
Take a lead role or participate in the provision of rehabilitation services.
Structuring Time and Employment
Provide individual vocational-supportive counseling to enable clients to identify vocational strengths and problems, establish vocational or career goals and plans to reach them, and recognize and target symptoms of mental illness that interfere with work.
Plan and provide work-related supportive services, such as assistance with grooming and personal hygiene, securing of appropriate clothing, wake-up, and transportation.
Teach job-seeking skills.
Develop individualized jobs based on clients’ needs, abilities, and interest.
Conduct on-the-job performance assessments and evaluations. Regular work review sessions with clients and their employers, on-the-job support, and crisis-assistance contacts.
Perform job coaching, problem solving , and support on and off the job site.
Coordinate with state vocational rehabilitation and other employment services.
Provide benefits counseling (e.g., Supplemental Security Income [SSI], Veterans’ Benefits).
Activities of Daily Living Services
Provide ongoing assessment, problem solving, side-by-side services, skill training, supervision (e.g., prompts, assignments, monitoring, encouragement), and environmental adaptations to assist clients with activities of daily living.
Assist clients to find and maintain a safe and affordable place to live--apartment hunting, finding a room-mate, landlord negotiations, cleaning, furnishing and decorating, and procuring necessities (e.g., telephone, furnishings, liens).
Assist and support clients to carry out personal hygiene and grooming task.
Provide nutrition education and assistance with meal planning, grocery shopping, and food preparation.
Assist and support clients to perform household activities, including house cleaning and laundry.
Ensure that clients have adequate financial support (e.g., help to gain employment or apply for entitlements).
Teach money-management skills (e.g., budgeting and bill paying) and assist clients in accessing financial services (e.g., professional financial counseling, emergency loan sources).
Help clients to access reliable transportation (e.g., obtain driver’s license and car, arrange for cabs, access bus line, find rides).
Assist and support clients to have and effectively use a personal primary care physician, dentist, and other medical specialists as required.
Social and Interpersonal Relationship and Leisure Time
Provide individual supportive therapy (e.g., problem solving, role playing, modeling and support), social-skill development, and assertiveness training to increase client social and interpersonal activities in community settings.
Plan, structure, and prompt social and leisure-time activities on evenings, weekends, and holidays.
Provide side-by-side support and coaching to help clients socialize (e.g., going with a client to a basketball game, coaching and supporting a client before he or she goes to a family reunion).
Organize and lead individual and group social and recreational activities to structure clients’ time, increase social experiences, and provide opportunities to practice social skills and receive feedback and support.
Support
Provide practical help and supports, advocacy, coordination, side-by-side individual support, problem solving, direct assistance, training, and supervision to help clients obtain the necessities of daily living including medical and dental health care; legal and advocacy services; financial support such as entitlements (e.g., SSI, SSDI, and veterans’ benefits) or housing subsides (e.g., HUD, Section 8); supported housing (e.g., adult foster care, paid roommates, meals brought in for those who need it); money-management services (e.g., payees’) and transportation.
Education, Experience, and Knowledge Required
Post-secondary school education and training is required, including internships and other supervised practical experiences in a clinical or rehabilitation setting with persons with severe and persistent mental illnesses. Must be licensed or certified to work in the field, abide by a code of ethnical and practice standards, and be committed to a process of a lifetime knowledge and skills development. People with a master’s or doctoral degrees in nursing, social work, rehabilitation counseling, or psychology are eligible as are registered occupational therapists. Must have a strong commitment to the right and ability of each person with a severe and persistent mental illness to live in normal community residences; work in market jobs; and have access to helpful, adequate, competent, and continuous supports and services. Skills and competence to establish supportive trusting relationship with persons with severe and persistent mental illness and respect for client rights and personal preferences in treatment are essential. Must have a valid driver’s license for the state of Georgia.