Hot Spotters in the HCH Setting: Managing Patients with Complex Comorbidities

Webinar Slides(PDF)

This webinar will present findings from a review of the literature and field interviews with four health care for the homeless projects regarding their management of complex comorbidities including a highlight of practices from the HCH project at Mercy Medical Center in Springfield, Masschusetts. Managing complex comorbidities with patients who are homeless can be very challenging for HCH providers. Many HCH projects lack specialty services, clinicians may have difficulty developing treatment plans and coordinating care, and patients may be troubled by complicated self-management routines. Judy Mealey, nurse practitioner and program manager at Mercy Medical Center will discuss their system for identifying ‘hot spotters’, patients with the most complicated diagnoses, and creating treatment plans for them using integrated care teams. The webinar will conclude with a description of how one health center in Nashville, Tennessee, is creating a chronic care center of excellence to ensure that its patients return for routine and preventive care.


  • Molly Meinbresse, MPH; Program & Research Specialist, National Health Care for the Homeless Council; Nashville, Tennessee
  • Judith Mealey, MS, ANP, RN; Program Manager, Nurse Practitioner, Health Care for the Homeless, Mercy Medical Center; Springfield, Massachusetts
  • Bill Friskics-Warren, MDiv; Director of Services for Homeless People, United Neighborhood Health Services; Nashville, Tennessee
  • Crystal Carey, Clinical Director, United Neighborhood Health Services; Nashville, Tennessee
Categories: Clinical Practice, Mortality, Severe Mental Illness, Substance Use
Tags: Webinar
Scroll to Top
Invest in hope and healing this holiday season

Your gift to NHCHC today will affirm the lives of unhoused individuals and support our efforts to provide in-depth training, increase understanding of homeless health care, and inform public policy.