Discharge Planner

Full-Time Exempt

Function as liaisons between the hospital and facilities and professionals representing the next stage in the continuum of care. Functions as a patient/family advocate. Works with the treatment team to execute and facilitate post-discharge treatment arrangements with outpatient clinics, private therapists, extended residential facilities, half-way houses, etc. Assists the Utilization Review department with all utilization activities as requested and directed. Participates in education on and implementation of clinical guidelines and protocols. Provides or arranges patient teaching as appropriate.  Participates in performance improvement and CQI activities.

Competencies:

• Expresses excellent judgment, discretion, and decision-making abilities.
• Demonstrates the ability to be flexible and organized; functions well during stressful and/or emergency situations. Ability to maintain control and respond calmly and appropriately in a crisis situation.
• Understands HIPAA regulations.
• Demonstrates an understanding of the disease concept of addiction and has a basic understanding of steps 1-4 of the 12 Step program.
• Understands compliance as it relates to the facilities licensing entities.
• Demonstrates the ability to act as a liaison between patients, each hospital, and the community.
• Knowledgeable in third party payer requirements.
• Demonstrates the ability to refer patients to appropriate resources in the community, as needed.
• Able to adequately assess and anticipate patient needs in home environment. Able to assess home environment support system and encourages development of support networks.
• Demonstrates thorough understanding of local, state, federal regulations Joint Commission standards.

• Proficient planning, time management and decision-making skills. 
• Demonstrates excellent conflict resolution skills; especially the ability to deescalate situations in an empathetic and professional manner. 
• Demonstrates knowledge of the facility's history, mission, services, and organizational structure.

Main Duties and Responsibilities: 

• Performs initial aftercare plan assessment.  Uses case management screening criteria appropriately, identifying any issues that may disrupt patient services.
• Establish treatment and discharge planning needs and financial ability and present information to treatment team.
• Participates in daily multidisciplinary meeting to discuss assessment, treatment planning, and ongoing discharge planning.
• Plans aftercare for the patient in collaboration with all members of the healthcare team.  Coordinates specialties when appropriate for optimal patient care.
• Intervenes with and counsels patients who are contemplating leaving treatment against medical advice (AMA) and coordinates efforts with interdisciplinary team members.
• Competently manages resistant/difficult patients, utilizing clinically relevant techniques.
• Act as a liaison between treatment team, EAP’s, providers, and referral sources regarding patient’s progress and anticipated aftercare needed with signed releases.
• Educates patient and family on all aspects of patient’s hospitalization and continuing care.
• Contact family members to verify information supplied by the patient.  Encourage the family to participate in family educational and support groups.
• Ensure documentation is complete, meets standards, policies, and established timeframes. Required spreadsheets and tracking forms are kept up-to-date and complete.
• Assures there is a plan for the patient to return from hospital to safe environment.
• Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services, including appropriate follow through.
• Promote the alumni program to patients and advise Alumni Coordinator of new patients.
• Inform alumni department of any contact with alumni, confirming updates to patient contact information, including phone number and/or email address.  Also, inform alumni department of patients in need of treatment via messaging.
• Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
• Demonstrates knowledge and ability to set appropriate professional boundaries and avoids entering dual relationships.
• Performs other duties as assigned.

Qualifications:

At least one year of experience in a Patient Advocate/Case Manager position working directly with patients is preferred.  Experience in behavioral health or chemical dependency is strongly preferred. Must have great interpersonal skills and exceptional organizational and time management skills. 

Knowledge of federal, state and local regulations relating to substance abuse programs and knowledge of Joint Commission and DCF requirements is preferred.  Proficient knowledge of Microsoft Office products (Word, Excel and Outlook) and the ability to navigate EMR systems required. 

Education:

Bachelor’s degree in social services, Psychology, Business, or related field.