Registered Nurse – CAPABLE

Registered Nurse – CAPABLE



The RN support LACHC’s mission (“to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare”) as well as adhering to policies, procedures, standards and regulations of the RN license and LACHC as an organization. The RN works with the care teams and functions as a service provider, educator, coordinator, advocate and facilitator of health and health services for individuals in the in-home setting. The RN works to improve the quality of patient care through ongoing communication and collaboration with the multidisciplinary care team, including assessment and case management for chronically ill patients. All duties must be performed in a manner displaying LACHC’s holistic approach to treatment, addressing physical, emotional, mental, social and spiritual barriers and contributors to health. Works collaboratively with partner organization in a flexible, creative, culturally competent manner to provide care for homeless clients.




Including but not limited to the following:
• Interview each resident in their home using validated assessment and survey instruments.
• Conduct a semi-structured clinical interview to identify and prioritize problem areas relating to medication, pain, depression, history of falls, physical functioning, strength and balance, and primary care provider communication.
• Engage residents in problem solving to identify behavioral and environmental contributors in the areas above, educate and refer to resources as needed.
• Work collaboratively with CAPABLE team members, including the Occupational Therapist, to assess resident’s progress and plan how to best address ongoing needs.
• Provide two to three additional home visits for follow-up and support.
• Determine a resident’s readiness to graduate from the program.
• RN will support the collection of data using specific validated instruments.
• Obtain resident releases to participate in CAPABLE program.
• In coordination with SRHT and USC, select validated assessment and survey instruments.
• Create CAPABLE project database and delivery vehicle for data submission to USC.
• Submit data to USC for analysis in agreed-upon timeframe.
• RN will make recommendations for adapting CAPABLE.
• Review information collected via assessments and during resident interviews.
• Document findings briefly in writing including challenges, successes and best practices. Submit recommendations in writing to USC evaluation team and discuss.
• As a member of the care team, provides basic medical case management to patients. This includes on an as needed basis: communicating with patients or families, helping execute a care plan, reconciling patient medications, providing interventions as appropriate, and helping with clinical follow up to ensure patient self-management or self-care goals are being addressed.
• Work closely with the partner organization to provide whole- person care for clients on the streets, practicing harm reduction approaches, considering creative and flexible solutions, and partnering with the clients to take steps forward with their health.
• Interacts with patient by phone, text, letter or email/portal.
• Carry out standing orders as appropriate and per policy.
• Document all patient interactions as deemed appropriate in the patient chart in the EMR, taking care to chart in an informative, accurate and descriptive manner that reflects the patient care provided and keeping accurate records on intervention and patient education. Documentation will be complete, prompt and according to policy.
• Provide patient education and information about chronic care, disease prevention and the promotion of health maintenance.
• Function as a member of the care team by participating in care team meetings-daily huddles and monthly site team meetings as appropriate.
• Utilize appropriate methods for interacting with and collaborating sensitively, effectively and professionally with persons from diverse backgrounds.
• Demonstrate ability to communicate with all members of the team to facilitate patient care.
• Serve as an advocate for the patient.
• Minister to the needs of the patients in a holistic manner, addressing needs of body, mind and spirit.
• Foster and promote a culture of service excellence and accountability.
• Abide by HIPAA guidelines and policies, taking care to protect patient information at all times.
• Prioritize daily workload to ensure that all responsibilities are carried out in a timely manner.
• Work independently and with minimal supervision.
• Other duties as assigned to including special projects and administrative duties.








To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
• Ability to make independent decisions when circumstances warrant such action.
• Ability to deal tactfully with personnel, patients, visitors, government agencies and the general public.
• Knowledgeable regarding nursing and medical practices and procedures, as well as laws, regulations and guidelines that pertain to community health.
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at times, hostile people within the home setting.
• Ability to demonstrate effective decision-making by assessing situations accurately, sharing fact-based information, communicating professional opinions clearly and inquiring actively.
• Ability to work autonomously, taking initiative and problem solving within the scope of an RN.
• Ability to manage a high volume of patients in a short span of time, while dealing with unpredictable issues.
• Flexibility to perform in an ever-changing work environment with frequent interruptions.




Diploma from an accredited nursing school. Bachelor’s degree (BSN) preferred. One year community or ambulatory health experience preferred. Experience in case management and in-home care preferred.




Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization. Bilingual (English and Medical Spanish) a plus.




Ability to calculate figures and amounts such as medication doses, proportions, percentages, area, circumference, and volume as well as others as appropriate. Ability to apply concepts of basic algebra and geometry.




Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.




Current, unencumbered, active California license to practice as an RN; CPR certificate.




The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand and walk in outdoor settings. The employee is occasionally required to sit, use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb or balance, and stoop, kneel, crouch, or crawl. The employee must occasionally lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.




The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually quiet. While performing the duties of this job, the employee will be exposed to carriers of contagious diseases. The employee may have to deal with irate and irrational clients who may or may not be under the influence of mind-altering substances such as cocaine, marijuana, alcohol, etc.

Job Category: Outreach
Job Type: Full Time
Job Location: Downtown Los Angeles

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