The Community Health Nurse will support Williams and Colbert Class Members in the transition process from institutional living to independent community living. The Community Health Nurse will support Williams and Colbert Class Members and clients on Community Support Teams (CST) to maintain their health while living in community settings.  They will provide supervision and consultation on medical illness, self-management, and medication monitoring, training, and medication reconciliation services.  They will collaborate with the treatment team, providers, and others on client plans of care to ensure quality standards are met.  The Community Health Nurse will provide strengths-based, client-centered, and trauma-informed services to clients with severe mental illness and co-occurring substance abuse/addiction disorders utilizing a harm reduction approach  

The nursing duties will be coordinated with the pre-transition treatment team, CST teams, Providers, and others involved in the client’s plan of care to ensure quality standards are met.  The Community Health Nurse will work with clients directly in the community (50-70%) engaging them in their home settings.  They will ensure reconciliation of medications and care as they transition into the community, attend doctor visits or any movement in and out of the facilities to ensure quality care is sustained.  

• Support the transition team in conducting preliminary assessment of clients’ health while in the nursing home; and develop medical treatment plan goals for the client to help them transition into independent community settings.   
• Educate the behavioral health team on client’s medical issues and provide care coordination services by communicating with physicians, specialists, pharmacies, home health providers, and inpatient/outpatient providers.  
• Provide psychoeducation, medication training and monitoring to clients according to Trilogy policy 
• Visit clients in their homes in the community to support health management and continuity of care. 
• Complete daily progress notes based on services provided to clients in a timely manner reflected in Trilogy’s documentation policy and agency standards 

• Assist clients in identifying signs and symptoms of de-compensation, assess for crisis situations and or the need for stabilization through hospitalization.  Work collaboratively with clients to identify coping skills to assist in managing symptoms and stressors experienced. 
• Communicate effectively within the team model for a multi-disciplinary approach to client care. 
• Participate in meetings, committees, and work groups as needed.  
• Potential for occasional phone availability off hours or on weekends to answer questions from staff on the team about specific clients that the nurse has a direct working relationship with to help give direction 
• Perform other related duties and/or projects as assigned.  

• Associate degree in Nursing required; Bachelor’s/Master’s preferred 
• Current Registered Nurse license in the State of Illinois.  
• Active BLS certification required 
• Minimum two years’ experience working with people with mental health and/or substance abuse diagnoses 
• Valid Illinois driver’s license with daily access to a well-maintained vehicle with $100,000/$300,000 liability insurance  
• Experience working with nursing homes highly preferred 
• Exceptional customer service skills and ability to interact with a diverse group of internal/external stakeholders 
• Clinical supervisory experience preferred