Assertive Outreach (Community Psychiatric Nurse)

Job overview

The Assertive Outreach Worker will deliver time‑limited and intensive support to adults with severe mental illness (SMI) who are at risk of disengaging from care. The role is central to stabilising engagement, reducing risk, and preventing crisis escalation, in line with the Assertive Outreach Standard Operating Procedure.

The postholder will:

Provide assertive, flexible, and persistent outreach, including home visits, community‑based contacts, and phone/text engagement.

Act as a consistent keyworker, building therapeutic relationships with individuals who find it difficult to engage with services.

Work within a stepped 6‑month model of intensive support, transition, and reintegration into routine CMHH care.

Deliver holistic, person‑centred interventions addressing mental health, physical health, housing, substance use, and social needs.

Work collaboratively with the CMHH MDT, crisis services, inpatient wards, and external agencies to ensure continuity of care and safe transitions.

The role requires strong clinical skills, excellent risk management, and the ability to work autonomously in the community.

Main duties of the job

Assertive Outreach Delivery

Provide intensive outreach in line with the SOP:

First 3 months: minimum 3 contact attempts per week, aiming for 1–2 successful contacts.

Next 3 months: minimum 2 contact attempts per week.

Deliver flexible contact through home visits, community meetings, phone calls, texts, and occasional evening/weekend availability.

Maintain a “no discharge for DNA” approach, using persistent and creative engagement strategies.

Build strong therapeutic relationships through empathy, reliability, and trauma‑informed practice.

Provide continuity and consistency as the allocated AO keyworker.

Detailed job description and main responsibilities

Clinical Responsibilities

• Complete and update care plans, risk assessments, and safety plans in line with Trust policy.
• Conduct frequent dynamic risk assessments and escalate concerns promptly.
• Lead on transition planning back to routine CMHH care.
• Ensure timely documentation of all contact attempts, outcomes, and risk assessments.
• Work collaboratively with the CMHH Care Coordinator where this is a separate role.
• Deliver meaningful intervention
• Use therapeutic engagement to support patients to engage.
• Supervision of band 4 support staff
• To hold case load of 10-15 patients.

Holistic Support & Multi‑Agency Working

• Address mental health, physical health, housing, finances, substance use, and social needs.
• Liaise with drug and alcohol services, social care, housing teams, and voluntary sector partners.
• Support individuals to access practical help such as housing applications, benefits, and community resources.
• Involve families and carers (with consent) to strengthen support networks.   In‑Reach to Inpatient Wards Provide continuity of care during hospital admissions. Attend inpatient wards to maintain engagement and support discharge planning. Ensure safe and coordinated transition back to community services. MDT Working & Communication Participate in daily zoning/MDT meetings and AO huddles. Share updates, escalate concerns, and contribute to joint care planning. Maintain strong links with crisis services, inpatient teams, and external agencies. Promote reflective practice and collaborative working within the team.
• Provide continuity of care during hospital admissions.
• Attend inpatient wards to maintain engagement and support discharge planning.
• Ensure safe and coordinated transition back to community services.
• Participate in daily zoning/MDT meetings and AO huddles.
• Share updates, escalate concerns, and contribute to joint care planning.
• Maintain strong links with crisis services, inpatient teams, and external agencies.
• Promote reflective practice and collaborative working within the team.