General Description

Under direction of the Program Manager of AOT Services and the DON (Director of Nursing) and within federal, state, and local guidelines provides quality nursing care to individuals in the AOT team using effective assessment skills while maintaining ethical standards of nursing and individual confidentiality at all times. Delivers care to individuals utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with individuals and other health care team members while maintaining standards of professional nursing. This position will work closely with both the justice and court systems to ensure comprehensive services and coordination of care for individuals served.

Promotes the physical and mental health of individuals by applying nursing processes. This is done as a member of the interdisciplinary treatment team and has the goal of assisting individuals to assume responsibility of their own health. The nurse coordinates and monitors medical services, including psychiatric and medication services, in accordance with the requirements of regulatory agencies and in response to the individual's needs. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

This is a Substance Abuse and Mental Health Services Administration (SAMHSA) grant funded position ending in September of 2028. Continued employment in this role is contingent upon the availability of additional funding. If further funding is not secured, the position will end on September 29, 2028.

Education, Training, and Experience

•   A high school diploma or equivalent and graduation from an accredited Nursing School required.
•   Must have and maintain a current RN license with the Board of Nurse Examiners in the State of Texas.
•   Three (3) years previous nursing experience and three (3) years prior experience working with persons with major mental illness preferred.
•   Experience working on a multi-interdisciplinary team preferred.

Registration, Certification, Licensure, and Other Qualifications

• Must have and maintain a current R.N. license in good standing with the State of Texas Board of Nurse Examiners.
• Must have valid Texas driver's license, proof of auto liability insurance, and maintain an acceptable driving record as defined by the Center's insurance carrier requirements.
• All job specific training must be completed within 30 days of hire.
• Must be able to perform the techniques of Prevention and Management of Aggressive Behavior (PMAB).
• Must be able to perform Cardiopulmonary Resuscitation (CPR).
• Ability to be mobile within the community to provide direct nursing services if needed.
• Must have and maintain a background and criminal history free from any disqualifying offenses as outlined by the Texas Administrative Code (TAC) and the Health and Human Services Commission (HHSC).
• Must possess and maintain a valid driver's license and automobile insurance.

o  Individuals with an out-of-state driver's license must be able to obtain a driver's license in the state of Texas within thirty (30) days.

•   Successful completion of all position-specific training within thirty (30) days of employment is required.

Knowledge, Skills, and Abilities

•   Knowledge of nursing techniques and procedures; of health care laws and regulations; of medical diagnosis and procedures; of accepted medical treatment programs; and of community health and nursing care principles, practices, and procedures.
•   Knowledge and background in mental health services. Knowledge of serious and persistent mental disorders, personality disorders and substance abuse/dependence syndromes encompassed in the DSM-IV.
•   Knowledge of common psychoactive medications used to treat neurobiological diseases of the brain.
•   Skills in the care and treatment of individuals, and in the operation of computers and applicable computer software.
•   Ability to provide individuals care, to prepare and maintain records, to explain public health laws, to recognize patterns of medically necessary treatment, to communicate effectively, and to train others. Moderate mathematics skills. Proficient reading, writing, interpersonal relations, and communicative skills.
•   Ability to make decisions based on education preparation and or nursing/clinical experience, which reflect consistency with Agency philosophy, policies and procedures and standards of care, to provide individuals care, to prepare and maintain records, to explain public health laws, to recognize patterns of medically necessary treatment, to communicate effectively, to train others, to read and comprehend simple instructions, short correspondence, and memos, to write effective case management notes, to effectively present information in one-on-one and in small group situations, to make decisions based on education preparation and or nursing/clinical experience, which reflect consistency with Agency philosophy, policies and procedures and standards of care. Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write effective case management notes, and to effectively present information in one-on-one and in small group situations.
•   Auditory and visual skills; ability to bend, stoop, sit, stand, reach, and lift items weighting 45 pounds or less; ability to talk and hear with aid greater than 2/3 of the time, ability to have clear vision at 20 inches or less; color vision (ability to identify and distinguish colors); peripheral vision (ability to observe an area up/down or left/right) and ability to adjust focus (ability to adjust eye to bring into focus).
•   Ability to display regular and reliable (in-person, if required) attendance.
•  Understanding and practice of Trauma Informed Care principles.

Essential Duties

The following list outlines key responsibilities for the position; however, it is not exhaustive and does not encompass all responsibilities. Additional duties may be assigned as needed.

1.  Completes skills training including but not limited to symptom management, medication management, and health/wellness. Review lab results and follow Abnormal Lab Procedure

2.  Provides direct nursing services, telephonic and/or home-based services in the individuals living environment, psychiatric clinic, or alternate care setting, for individuals being served on the AOT team. Provides a collaborative assessment, by interviewing the individual served.

•  Performs and documents professional and comprehensive psychiatric and appropriate physical nursing assessments as outlined in the Nursing Practices Act
•   Provides medication education and training using the Denton County MHMR Center assigned program materials.
•   Orders laboratory reports as ordered by the physician. Analyzes and secures physician's signatures as appropriate and per procedures.
•   Perform vital signs and weight measurement as part of initial or follow-up procedures.
•   When indicated, provides safe and effective home-based nursing services in the individuals living environment for the purposes of assessment, medication administration, and crisis intervention.

3.  AOT client Intake : 

•   AOT nurse is responsible for following up to verify medications of any new AOT client. (A medication count and pharmacy contact for RX verification should be done prior to Psychiatric Evaluation. Information should be put in a contact note and emailed to AOT provider).
•   Get clarity on client insurance coverage for medication
•   Get consent for Medical provider and any specialty provider treating the client.
•   Obtain information about primary care provider and medical medications.

4.  Will consult with psychiatrist or APN as needed regarding symptoms and side effects for individuals.

•  Documents all services provided to an individual or on behalf of an individual in a progress note to be entered in the individual's medical record. Each service delivered will be documented according to agency and stated guidelines to also include any clinically significant information and in the case of a crisis and/or emergency.
•   Documentation for each service is to be completed as per center policy or sooner for appropriate timely communication of care. Supervises self-administration of medication.
•  Any schedule changes regarding get medication boxes and/or LAIs, are required to have GMO completed unless otherwise advised by the provider.

5.  Follows appropriate medication procedures:

•  May telephone medication orders per physician orders.
•   May monitor medication compliance and adherence to treatment.
•  May administer medication as ordered by the physician.
•  Nurse should ensure that a medication consent is completed following any medication changes.
•   Nurse will ensure that there is valid written consent prior to giving LAI ( Long acting Injection).
•  Nurse will ensure that PAP and RXO medication Refills are ordered prior to client needing refills.

6.  Provides medication education and training to individuals served and consultation to AOT Team staff.

•  Develops medication education and training curriculum and implements when/where appropriate.
•   Provides medication training and other training for AOT Team staff.
•  Provides family education and training to family members, relatives, and friends who constitute individuals served social support system in the community.

7.  Provides symptom management and education with the focus of resolving current medical/mental situation while assisting the individual to be an active participant in their treatment.

•   Provides symptom management and education with the focus of resolving current medical/mental situation while assisting the individual to be an active participant in their treatment.

8.  Medical Care Coordination:

•   Obtain information about primary care provider and medical medications ordered for client.
•  Get consent for Medical provider and any specialty provider treating the client.
•   Help connect client to medical provider or Integrated care or indigent health care as appropriate. Request copy of labs/ test results from medical provider
•   Follow up on labs/EKG that are ordered by AOT prescriber.

9.  May conduct physical, developmental, and psychosocial assessments to determine eligibility for health services.

•   Instructs, counsels, and assists individuals in meeting their health care needs. Monitors and reviews case management service plans.

10.  Refers per protocol to the most effective and least restrictive approach to the behavioral health emergency which may include consulting with the on-call regarding medication initiation, continuance, or adjustment.

11.  Participates through a collaborative effort in developing and implementing a comprehensive crisis plan that provides the most effective and least restrictive available treatment.

•   This plan is based on the provisional psychiatric diagnosis and will incorporate all requirements listed in the protocol and or procedure related to crisis services including reassessment needs adjustment to individual's response, coordination, resolution of crisis and transference to appropriate package

12.  Communicates effectively following procedures with Denton County MHMR daytime, weekend, or evening teams as appropriate to provide continuity of care.

•   Communicates effectively following procedures with Denton County MHMR daytime, weekend, or evening teams as appropriate to provide continuity of care.

13.  Provides case coordination activities for AOT Team consumers.

•   Serves as a Case Manager on an as needed basis.
•  Provides care and case management by referring consumers to appropriate community services.
•   Monitors continuity and adequacy of consumer services within and outside the Center.

14.  Practices workplace safety procedures.

•   Adheres to the use of Universal Precautions.
•  Adheres to the Center Infection Control Plan.
•  Informs appropriate staff of any safety hazard or issue promptly.
•  Completes and monitors for compliance of all documentation in accordance with federal, state, and Center standards.
•   Develops individual's service plans and monitors them for appropriateness to the individual's needs. and compliance to Texas Department of Health and Human Services (HHSC) and Texas Administrative Code (TAC).

15.  Attends regularly scheduled meetings.

•   Regularly scheduled staff meetings.
•   Regularly scheduled staff training.
•   All scheduled clinical team meetings.

16.  Serves as a member of the MDT (Multi-Disciplinary Treatment Team) process.

•   Attends and provides nursing expertise at treatment planning staffing's.
•   Presents nursing assessments and recommendations at treatment team meetings.
•   Presents overview of individuals seeking Centers services at MDT staffing.
•   Provides documentation in accordance with scheduled treatment staffing.
•  Maintains a current level of knowledge about individuals served changing needs and living circumstances and response to services.

17.  Provides emergency intervention when necessary, according to Department of Human Services (HHSC) and Center rules and procedures.

•  Provides verbal and physical Prevention Management of Aggressive Behavior (PMAB) intervention correctly when necessary.
•   Provides Cardiopulmonary Resuscitation (CPR) in an emergency until other medical aid arrives.
•   Provides emergency and non-emergency first aid until professional medical aid arrives or as directed by licensed medical professional.

18.  Contact supervisor or designated back-up for clarifications of procedures or clinical assistance as needed. Serves as a member of the MH Nursing on-call rotation system. Provides nursing backup by telephone and as a Qualified Mental Health Professional (QMHP) after hours and on holidays when scheduled to do so.

19.  Participates in the Center's Zero Suicide Initiative.

o  Supports individuals experiencing a crisis by promptly connecting them with appropriate Center programs, such as the Mobile Crisis Outreach Team (MCOT), Psychiatric Triage, Crisis Prevention services, and/or other applicable resources. Ensure seamless coordination to facilitate timely intervention.

o  Remains with individuals, when deemed safe, to provide support and maintain a calm environment until specialized crisis staff or emergency personnel arrive to take over intervention efforts. Adheres to safety protocols to prevent escalation of the crisis situation.

o  Participates in debriefing sessions with the immediate supervisor or designated staff following a crisis event. Collaborate with the team to review the incident, identify lessons learned, and ensure all HHSC guidelines and Center policies are followed.