HCH Nurse Care Coordinator

Catholic Medical Center Manchester, NH

HCH Nurse Care Coordinator insures that homeless patients have access to care and services at HCH program. HCH Nurse Care Coordinator addresses complex medical and behavioral health needs of homeless patients using the nursing process to conduct in-depth assessments, to identify co-occurring medical, mental health and substance use disorders presented by homeless patients. Nurse provides care coordination, chronic disease management, counseling and health education, as indicated, promoting a therapeutic environment, as part of an interdisciplinary team, at a shelter-based HCH clinic and community setting.


With guidance as needed from the HCH Nurse Staff Coordinator and within established state, federal and hospital policies and procedures and program expectations, the incumbent performs the following functions:


a. Perform Triage and Rapid clinical assessments for patients who present at HCH shelter-based clinics, in partnership with behavioral health team; assess for medical or psychiatric crisis; intervene as indicated during Triage.

b. Initiate appropriate emergency response in life-threatening or unusual situations in order to stabilize the client; promptly and directly notify HCH provider

c. Assess patient intake screening, health assessment and psychosocial history; perform comprehensive bio-psycho-social assessment; document in electronic medical record (EMR).

d. Conduct mental health screening and substance use disorder screening using evidenced based tools such as PHQ2 , PHQ9 and SBIRT

e. Initiate appropriate diagnostic point of care testing and health maintenance protocols upon intake

f. Refer patient to appropriate level and category of care on multidisciplinary HCH team, based upon assessment.

a. Assess and record patients' vital signs, physical signs and symptoms, and presenting complaints in preparation for clinic visit with medical or behavioral health provider.

b. Insure that pertinent clinical information, such as diagnostic results and consult reports, are up-to-date in medical record in preparation for clinic visit by provider.

c. Communicate and convey assessments and screening outcomes to providers and other members of the HCH team, as patient enters exam room phase of clinic visit.

d. Identifies health problems and learning needs of the client.

e. Monitor patient's health status and ability to manage health/chronic illness in addition to their struggle with homelessness

Care Planning / Implementation and Evaluation:

a. Develop an individualized care plan based upon nursing assessments of bio-psycho-social needs, in collaboration with interdisciplinary team as indicated.

b. Provide health education and counseling to patient in support of self – care and health management goals.

c. Coordinate discharge plan for each clinic visit; arrange referrals for diagnostic and specialty care, with support for transportation, escort, medication assistance and translation as needed.

d. Where possible and with patient consent, incorporate family members and homeless service agency case workers in the planning of care.

e. Develop and implement care plans based upon thorough assessments and evidenced based chronic care management guidelines and in collaboration with patient and with other members of the HCH team.

f. Devise Care plans to assist patients to achieve recovery, self-care goals, and to end their personal struggle with homelessness.

g. Provides for multidisciplinary case coordination through case management discussions with other members of HCH team, including Behavioral Health Providers.

h. Coordinate all aspects of care to insure continuity of care within HCH team and to insure access to all required diagnostics, specialty care and services in the community.

i. Coordinate with health insurance carriers to obtain prior authorizations for procedures, diagnostics and medications, as indicated.

j. Provide and document face to face nursing care visits and patient encounters, as indicated for health education and chronic disease management; provide health education to individual patients and to patients in group settings; and in a culturally competent manner.

k. Provide telephone triage to coordinate care, educate patients and address needs of patients who seek assistance by phone; intervene and document in EMR as phone note.

l. Performs nursing care interventions as ordered by provider and in support of the provider for medication administration, point of care testing, and diagnostic procedures during each clinic session.

m. Insure patient dignity during all interventions and the provision of care; promote calm and therapeutic decorum and environment at clinic; demonstrate courtesy and respect to patients, team members and community partners.

n. Assess patient safety in the context of shelter, transitional housing, or home setting; intervene as indicated.

o. Assess patient's adherence, response and progress with to care plan, in collaboration with HCH team; adjust and revise plans of care accordingly.



* Graduate from an approved school of nursing.

* BSN preferred.


* A minimum of 3 years of professional nursing experience

* Community health experience

* Case management experience

* Psychiatric Nursing experience

* Experience or interest in work with vulnerable populations


* Licensed in State of NH

* Basic Life Support (BLS) certification required.

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