Discharge Planner - Discharge Planning 128

JOB SUMMARY: The Discharge Planner at Psychiatric hospital/Crisis Stabilization Units (CSUs) is responsible for ensuring that consumers are discharged in a timely and appropriate manner, coordinating follow-up health care, assessing financial resources, and making referrals to appropriate community resources. The Discharge Planner plays a critical role in bridging inpatient care with outpatient and community-based support, ensuring continuity of care and optimizing patient outcomes.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES: The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification with or without an accommodation. It is not necessarily descriptive of any one position in the class. The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position.

• Develop comprehensive discharge plans tailored to each consumer’s need and perform actions to address such needs, for, at a minimum include follow-up post hospital discharge behavioral health –––appointment, information on how to obtain prescribed medications, information pertaining to available living arrangements; transportation; and referral to: 1. Care coordination services if the patient meets criteria as a member of a priority population as determined by the department under s.394.9082(3)© and is in need of such services. 2. Recovery support opportunities under s.394.4573(2)(l), including, but not limited to, connection to a peer specialist; considering both hospital and community resources.
• Participates in treatment team meetings as scheduled and provides salient information to the team on behalf of assigned consumers that communicated treatment progress, forecasts future course of treatment and facilitates discharge planning.
• Collaborate with the multidisciplinary team to assess patient readiness for discharge and identify necessary support services.
• Coordinate with nursing homes, group care homes, other acute hospitals, or other facilities for patient transfers as needed.
• Accurately assess patients' financial resources and insurance coverage to identify potential barriers to discharge.
• Make referrals to community agencies and/or internal programs/services that can provide assistance related to finance, transportation, housing, and other necessary support.
• Document all aspects of the discharge plan in the electronic medical record, ensuring accuracy and completeness.
• Complete final discharge documentation within two working days of consumer discharge.
• Serve as a vital member of the multidisciplinary clinical team, providing insights and advocating for consumer needs.
• Facilitate communication between the hospital/CSU, consumers, families, and community resources to ensure a seamless transition from hospital/CSUs to home or other care settings.
• Attends all meetings as assigned by the Manager and/or Director of Acute Care Services or otherwise by Lifestream
• The ability to comply with the regulations requiring a workplace of dignity and respect and equal employment opportunity compliance

• The ability to work collaboratively with others and to accept constructive criticism from supervisors and managers
• Willingness to abide by the company’s published rules and regulations
• Any other duties as assigned by Leadership

JUDGMENT/DECISION MAKING: Utilizes established corporate policies and procedures in making decisions. Uses sound judgment in meeting the responsibilities and performing the duties of the position.

ESSENTIAL SKILLS:  Strong knowledge of social work theories, skills, and interventions. Expertise in discharge planning and familiarity with community resources. Proficiency in medical terminology, medical charting, and navigating a healthcare setting. Ability to manage stressful situations effectively, including interactions with physicians, patients, and families. Counseling skills to address social issues and resolve discharge planning challenges. Capability to work collaboratively within a multidisciplinary team and establish productive relationships with community resources. Independent judgment and initiative in problem-solving. Skills in financial assessment and providing referrals to appropriate resources.

EDUCATION & EXPERIENCE: 

• Education: Bachelor’s degree in social work, counseling, psychology, or behavioral healthcare/human services-related field; Master’s degree preferred.
• Experience: Minimum of one year of experience in a behavioral healthcare/human services-related setting

TRAINING & DEVELOPMENT: Completes all requirements according to Individual Training Plan within the first six months of hire and annually.  Other training and/or professional development may be assigned due to evolution of programs.