Duties and Responsibilities:
Work with the TOR project team to develop, coordinate, and monitor the delivery of TOR services in accordance with the RSBCIHI TOR implementation plan, data collection and evaluation plan, quality improvement plan, and sustainability plan.
Work with the TOR project team to develop new intervention protocols, when needed.
Coordinate and deliver medical staff member training in RSBCIHI plans, protocols, and evidence-based practices.
Assist with coordinating meetings and attend project-related meetings with the TOR project team, other RSBCIHI staff members, including the Integrated Care Committee.
RN Case manager utilizes all validated tools of assessment and care including ASAM Whole Person criteria, Adverse Childhood Experiences, Clinical Opioid Withdrawal Scale, Treatment Needs Assessment (Hub & Spoke), OBOT (Hub & Spoke), DAST-10
Provides ongoing management of OUD and other medical issues, including drop-in or same day visits, management of acute issues, coordination of prior authorization requests, communication with pharmacists, and perioperative care coordination
Manages weekly case reviews with MDs and SUD counselors, identifying ongoing care needs with the team.
Manages all Buprenorphine/naloxone refill orders with Provider. Entering orders, per Provider instructions.
Writes and updates with the DEA waivered MDs and RN any patient information handouts, providing consistent information.
Maintain DEA compliance and design the program so access to information when DEA requires will be easily accessed.
Attend SAMHSA webinars, teleconference calls, and national meetings when requested.
Other duties as assigned
Licensed Registered Nurse or Nurse Practitioner
ANCC certification in addiction preferred
Experience working in an substance use treatment environment preferred
Experience working with American Indian/Alaska Native populations preferred.
Experience working with SAMHSA on grant projects preferred.
Nurse Case Manager Role in MAT program
1. Takes referrals from providers, from outside agencies, from patients directly. Provides initial MAT screening and schedules for a Nursing Assessment.
2. RN Case manager takes a complete assessment of patient using the Nursing Assessment template in eCW.
3. RN Case manager utilizes all validated tools of assessment and care including ASAM Whole Person criteria, Adverse Childhood Experiences, Clinical Opioid Withdrawal Scale, Treatment Needs Assessment (Hub & Spoke), OBOT (Hub & Spoke), DSM-% Opioid Use Disorder screen.
4. After patient is assessed for admission, RN consults with team to discuss admission, barriers, appropriate level of care, possible referrals to another MAT program or to Hub.
5. RN begins induction planning with waivered Provider, determining best induction plan: home induction, in-clinic induction or induction in social detox setting.
6. Referral to Provider for MAT medical clearance and labs including HIV
7. Induction planning and scheduling with Provider.
8. RN manages all induction care, making sure patient has education regarding induction, comfort medications, first buprenorphine/naloxone prescriptions and handouts with instructions.
9. Follows induction daily for first 7 days as patient stabilizes and begins to attend group.
10. Educates patient on program requirements and schedules patient for hand-off to SUD counselor for Treatment Agreement and Treatment Planning and Hub& Spoke enrollment.
11. Schedules patient for BH Biopsychosocial intake within 30 days of admission.
12. Monitors all UDS as patients stabilize and for s/sx of relapse. Participates in supportive interventions with or without other members of the MAT team.
13. Manages weekly case reviews with MDs and SUD counselors, identifying ongoing care needs with the team.
14. Manages all Buprenorphine/naloxone refill orders with Provider. Entering orders, per Provider instructions.
15. If patient needs referral to Hub or other higher level of care, RN manages the transfer or admission to other facilities.
16. RN can develop the weekly Refill/Stabilization Group curriculum and share the facilitating duties with Providers and with the SUD Counselor.
17. RN manages and updates the Buprenorphine Patient Roster weekly and makes it available for any DEA visits.
18. RN schedules patient as needed in the Provider’s schedule for any buprenorphine/naloxone dose changes or other MAT r/t questions. RN schedules patient with their PCP for all other medical needs.
19. RN consults with Provider and SUD counselor as patient progresses to Phase 2 and Phase 3.
20. RN Case manager participates in the educational needs of the clinic, available to teach about the best practices and purpose of the MAT program to improve over-all clinic culture towards treating OUD in clinic.
21. RN case manager works with all agencies to advocate for care and access for MAT patients, including jails, hospitals and Emergency departments, county agencies, courts and recovery providing facilities. Occasionally, visits to other settings such as jails and hospitals will be required.
22. RN case manager might also be required to attend and participate in local opioid coalitions.
23. RN Case Manager attends required MAT trainings and continuously updates MAT best Practices and research.