Discharge Care Coordinator

SUMMARY

The purpose of this position is to coordinate discharges with a community-based hospital transition team for patients discharged from the emergency room and inpatient psychiatric units. The Discharge Care Coordinator will be responsible for ensuring successful transitions of care through the provision of coordinated discharges to a community-based clinical team. They will support community-based care referrals and sharing of treatment recommendations through the HFS-funded Healthcare Transformation grant opportunity. The Collaborative Bridges team is an innovative care coordination pilot program to connect individuals and families with substance abuse and mental health needs upon their discharge from Westside Safety Net hospitals and provide support with therapy and care coordination services until linked to long-term community providers or consumer needs are resolved.

AGE/PATIENT POPULATION(S) SERVED DEFINITION

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. 

1. Ability to be respectful of the diverse cultures of the people served and to provide culturally appropriate, competent, and individualized treatment according to each client's age, gender, race, ethnicity, and culture.
2. Provide trauma-informed brief therapy for individuals with mental health needs to ensure successful community stabilization and transitions of care from hospital settings.
3. Assist with ensuring hospital discharge recommendations are understood by the consumer and followed through with by the patient.
4. Coordinate discharge planning with the community-based Collaborative Bridges stabilization team.
5. Act as liaison to the Collaborative Bridges team to facilitate relationships with hospital staff.
6. Ensure interventions are recovery-oriented, culturally congruent, and developmentally appropriate.
7. Understand risk assessment, safety planning, and de-escalation interventions, integrating Zero Suicide/Suicide Safer Care principles.
8. Engage natural and family support to strengthen an individual’s participation and engagement.
9. Provide warm linkage, care coordination, and resource acquisition services as indicated.
10. Ensure successful linkage to long-term care providers as indicated.
11. Maintain high-quality documentation of all case work, completed in a timely manner, and consistent with outlined program policies and licensure requirements.
12. Prepare written service plans, incorporating input from consumers, families, involved service providers, and wraparound team members, and clearly identify problem areas and needs, strategies, and service objectives.
13. Work collaboratively with interdisciplinary teams and health care team members both internal and external to the organization to improve patient care through effective utilization and monitoring of health care resources.
14. Perform other duties as assigned.

COMPLIANCE RESPONSIBILITIES

• Understands and adheres to Loretto Hospital’s compliance standards as they appear in the Compliance Policy, Code of Conduct and Conflict of Interest Policy. 
• Keeps abreast of all pertinent federal, state and Hospital regulations, laws, and policies as they presently exist and as they change or are modified. 

JOB REQUIREMENTS:

• Bachelor’s degree in Behavioral Health related field and a minimum of one year of related experience.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

EDUCATION AND/OR EXPERIENCE:

• Cultural humility and ability to build trusting relationships with consumers.
• Clinical competencies as aligned with training mandated by Collaborative Bridges governance.
• Knowledge of and ability to use appropriate behavior management techniques.
• Understanding of personal and professional boundaries.
• Ability to plan, develop and manage multiple projects.
• Organizational skills.
• Time and stress management skills.
• Communication skills include interpersonal, teamwork, and collaboration skills.
• Conflict resolution and diplomacy skills.
• Computer literacy.
• Problem-solving skills.
• Excellent interpersonal, verbal, and written communication skills.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, “Job Duties” are essential job functions.

PHYSICAL DEMANDS:

While performing the duties of this job, the employee is frequently required to sit, stand and walk as well as occasionally stoop, kneel or crouch.  Normal or corrected vision, hearing and ability to speak are necessary. Specific vision abilities required include close vision, sharp eye focus and ability to distinguish colors. There may be periods of stressful, intense concentration with more than average pressure used in a variety of problem solving situations.