The program targets populations with behavioral health needs who are at high risk for additional chronic conditions, including those with serious persistent mental illness, serious emotional disturbance, and opioid substance use disorders. Health Homes offer participants enhanced care coordination services from our psychiatric rehabilitation programs, mobile treatment service programs, and opioid treatment programs. Health Homes are designed to enhance person-centered care, empowering participants to manage and prevent chronic conditions in order to improve health outcomes, while reducing avoidable hospital encounters. Health Homes provide six core services, as follows:

• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Comprehensive Transitional Care
• Individual and Family Support
• Referral to Community and Social Support

• Develop wellness & prevention initiatives.
• Lead various patient group activities to enhance the therapeutic impact on patients and to improve skills.
• Facilitate health education groups and provide direct health and prevention education to participants and caretakers/guardians, as appropriate.
• Participate in the initial treatment plan development for all of their Health Home enrollees.
• Assist in developing treatment plan health care goals for individuals with, or at risk for, co-occurring chronic diseases.
• Consult with Community Support Staff about identified health conditions.
• Assist in contacting medical providers & hospitals for admission/discharge.
• Provide training on medical diseases, treatments & medications.
• Track required assessments, screenings and immunizations.
• Assist in implementing health technology programs & initiatives.
• Monitor HIT tools and reports for treatment, medication alerts and hospital admissions/discharges.
• Monitor and reports performance measures and outcomes.
• Participate in the evaluation of program effectiveness and efficiency and works to ensure continuous improvements in the quality of services.

• Work requires knowledge of nursing theory, principles, and practice-normally acquired through graduation of an accredited program of Nursing.
• Requires possession of a current license as a Registered Nurse in the State of Maryland at the time of appointment.
• Ability to coordinate primary and behavioral health care to address the whole-person needs of participants at both the individual and population levels.
• Work requires analytical ability and sound nursing knowledge for the effective formulation of nursing care plans, implementation of care, and appropriate documentation of pertinent information regarding a patient s condition.
• Must have excellent interpersonal skills and the ability to interact effectively with psychiatrically ill patients in order to gain their cooperation, allay apprehensions and provide effective health education to patients and family members.
• Must possess the ability to physically intervene, transport patients, and assist in the lifting of a patient.
• Conversant with electronic health records and data analytics. Skills and experience in fundamental MIS design and basic computer skills including knowledge of Microsoft Office programs.
• Does NOT require previous Psychiatric Nursing experience.