Discharge Care Coordinator

The Discharge Care Coordinator ensures that there are appropriate appointments for follow-up care, safety plans, transportation, living arrangements, and prescriptions for any medications that may be needed following discharge. Helps patients smoothly transition from inpatient services to outpatient services. Responsible for working with the treatment team in determining a psycho-social-emotional needs assessment, completing trauma informed care discharge plans, assisting patients and their families with accessing community resources, providing rehabilitative services, and initiating crisis intervention when needed.

Essential Duties:

·         Conduct thorough assessments of patients' mental health status, treatment history, and support systems to identify their specific needs and challenges

·         Collaborate with multidisciplinary teams, including psychiatrists, psychologists, social workers, and nurses, to gather relevant information and insights

·         Create individualized discharge plans in collaboration with patients, caregivers, and healthcare providers, incorporating input from treatment teams and considering patients' preferences and resources

·         Identify and address potential barriers to successful discharge, such as housing instability, lack of social support, and financial constraints

·         Coordinate with community resources, including outpatient mental health clinics, housing assistance programs, vocational rehabilitation services, and peer support groups, to establish post-discharge support networks for patients

·         Maintain accurate and up-to-date documentation of patient assessments, discharge plans, progress notes, and referrals

·         Monitor patients' progress and adherence to discharge plans through regular follow-up contacts, phone calls, and appointments, adjusting plans as needed based on changes in patients' circumstances or treatment goals

·         Foster effective communication and collaboration with internal and external stakeholders, including healthcare providers, social service agencies, community organizations, and insurance companies, to ensure continuity of care and seamless transitions for patients

·         Participate in interdisciplinary treatment team meetings to discuss patient progress, treatment recommendations, and discharge planning strategies

Education and/or Licensure – Bachelor’s degree preferred – or high school diploma and a minimum of two (2) year’s equivalent work experience required. 

Experience – Two years’ experience in healthcare or healthcare-related case management or court liaison duties – or one (1) year related experience in a psychiatric health care facility; direct practice in mental health treatment and experience in crisis intervention and customer service preferred.

Additional Requirements – Bi-lingual English/Spanish preferred but not required.

Knowledge Skills and Abilities

·         Knowledgeable of patient rights and laws (i.e. EMTALA) pertaining to mental health and regulations pertaining to psychiatric nursing and the treatment of the mentally and emotionally disturbed patients.

·         Must have the ability to exercise a high degree of diplomacy and tact; excellent customer services and interpersonal communication skills; Cultural sensitivity and demonstrated ability to work with diverse people groups.

·         Basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crises intervention practice, medical, psychiatric emergency procedures, and crisis intervention skills.

·         Communicate effectively with a variety of individuals and function calmly in situations which require a high degree of sensitivity, tact, and diplomacy.

·         Ability to exercise appropriate judgment in answering questions and releasing information in accordance with HIPAA and Personal Health Information Act requirements; analyze and project consequences of decisions and/or recommendations.

·         Ability to handle confidential information with great sensitivity.

·         Well-developed verbal and written communication skills in English. Skill to communicate effectively in order to exchange and/or provide information, build and/or maintain cooperative relationships.

·         Skilled in problem solving, prioritizing and time management.

·         Ability to document Case Management/Discharge plans in a clear and concise manner.

·         Knowledge of state and federal programs and regulations that govern hospital discharge planning and those providing medical care and financial support to individuals, community resources.

·         Ability to work on multiple tasks or parts of tasks simultaneously to ensure timely completion of work activities.

·         Usually works forty (40) hours per week, including weekends.

·         Must be able to multi-task, prioritize with strong time management skills.

·         Exceptional follow through on tasks and assignments

N/A, PRN status.