Health Home Management at Community Healthlink provides integrated primary and behavioral health care services in our outpatient clinics for our consumers with severe and persistent mental illness and/or a chronic substance use condition. The integrated model includes nurse care managers who coordinate care with the behavioral and primary care providers, perform wellness assessments, develop wellness treatment plans and develop and facilitate wellness activities. Clinic staff include primary care clinicians, licensed psychologists, licensed independent clinical social workers, licensed mental health counselors, drug and alcohol counselors, psychiatrists, advanced practice psychiatric nurses, nurses, medical assistants, and administrative support staff. The clinic offers open access to services daily for our consumers and our priority population. The clinic offers substance addiction treatment including medication assisted treatment using evidence-supported models.

The Community Nurse will provide nursing assessment, treatment, education and health care service coordination to individuals and families. Focus is on promoting and maintaining an optimal level of health. The nurse collaborates with all components of the team and other health care agencies to ensure coordinated, comprehensive services. Services will be provided at CHL and outreach locations.

• Complete nursing assessments of clients screening for but not limited to such diseases as diabetes, hypertension, tuberculosis, etc.
• Identify medical, emotional, and social problems requiring further assessment and treatment
• Provide appropriate health care and coordinate referrals as needed.
• Facilitate referrals to primary care provider or establish contact with existing primary care provider
• Contribute to the development of treatment planning process particularly as related to medical issues.
• Establishes realistic goals; documents clear, concise plans of care; regularly updates plans of care based on change in health status. Plan of care is made involving the client, family and team members when appropriate
• Works with individual clients on wellness initiatives such as: smoking cessation, improved nutrition, increased physical activity, and stress management, and follows through with all medical care recommendations
• Facilitate educational groups regarding nutrition, physical activity, smoking cessation, stress management, and medical needs for clients. Provide educational support to increase knowledge base of clients and mental health providers regarding medical conditions. Plan and facilitates wellness activities
• Maintain regular contact between the consumer, primary care, and primary and psychiatric providers, utilizing existing family and social supports as well
• Promote adherence to prescribed treatment protocols
• Attend team meetings, staff meetings, case conferences, and collaborate with other providers as needed
• Records all assessments, treatment plans, and follow up data in the electronic medical record system daily
• Meet with supervisor on a regular basis
• Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors
• Performs other related job duties.

• Valid and current license as a Registered Nurse in the Commonwealth of Massachusetts
• Bachelor's degree in nursing preferred
• Experience in the area of practice is necessary
• Knowledge of person-centered strength-based communications and relationship with consumers using recovery-oriented principles
• Proficiency in standard nursing practice including assessment, intervention and evaluation
• Ability to communicate effectively and professionally with consumers, staff and providers.
• Proficiency in completing electronic documentation in compliance with grant requirements, agency, state, and federal guidelines and policies
• Strengths/Experience in Wellness oriented care plans including nutrition, physical activity, tobacco cessation, and stress management.
• All candidates will be subject to a CORI review as outlined in the regulations set by the Massachusetts Executive Office of Health and Human Services. For more information, click here.