Overview

JOB DESCRIPTION – POSITION REQUIREMENTS

JOB TITLE: DISCHARGE PLANNER

CC/Department: 6341 Geriatric Behavioral Health

Reports to: Department Director

MISSION STATEMENT

Will deliver and manage excellent services and systems of care for persons with serious acute mental illness.

POSITION OBJECTIVE

The psychiatric unit discharge planner provides intensive discharge planning and other case management support to patients and their families.

POSITION SUMMARY

The discharge planner provides services related to discharge planning/case management to the acute geriatric psychiatry unit. This includes but not limited to assessment of patients on admission, assistance on social and/or financial resource management, crisis management, service delivery planning and follow-up, and referrals to community-based services and programs. This position also provides individual and group counseling, communicates with families and patient’s authorized representatives, conservators, physicians and other health team members. He/She coordinates discharge planning, assists with advance health care directives, financial and legal issues and maintains documentation of services in the medical record. The discharge planner participates in the development and implementation of the comprehensive treatment plans, leads the weekly reviews and coordinates the discharge plan with the team.

QUALIFICATIONS

One (1) year of direct service experience with mentally ill individuals in an inpatient or outpatient setting is required. A Degree in Social Work from an accredited graduate school of Social Work or Behavioral Science or any related field. Necessary skills include the ability to work effectively as a member of a multidisciplinary team, a thorough understanding of client rights, and understanding of the commitment process and knowledge of basic medical and psychiatric terminology. Familiarity with behavioral health resources in the community is desired. Current CPR Card may be required. Successful completion of applicable background checks is required. The discharge planner should be familiar with the rules and regulations governing psychiatry including appropriate documentation in accordance with all Medicare and Medi-Cal regulations, and should be experienced working with Electronic Medical Records (EMR) and LEAN principles.

CLINICAL RESPONSIBILITIES

• Maintaining safe environment- participates in unit safety rounds
• Fall precautions
• Elopement precautions
• Assault precautions

KEY RESULT AREAS

MISSION, VALUES AND BELIEFS

• Demonstrates the AHMC mission, purpose, values and beliefs in everyday language and contact with patients, the public and other staff members.

QUALITY AND QUANTITY OF WORK

• Provides safe, effective and efficient implementation of direct care in accordance with established policies, procedures and standards of care.
• Establishes and maintains a therapeutic relationship with patients and their families.
• Attends and participates in primary therapy, community meetings, family therapy, and groups.
• Assumes overall responsibility for discharge planning, including:

• Provides consultation to patients and their families regarding issues arising from the admission, discharge and/or aftercare plan.
• Provide direct treatment for assigned patients and families.

TEAM MEMBER PARTICIPATION

• Participates as a team member and provides input via reporting observations, concerns and asking appropriate questions.
• Reviews and implements patient treatment plans.
• Actively facilitates and participates in multidisciplinary team meetings and treatment planning meetings.
• Demonstrates knowledge of management of assaultive behavior techniques.
• Provides leadership in facilitating the team process.
• Provides education/training to other team members as necessary.

ASSESSMENT

• Observes, records and reports patient social and psychiatric behavior.
• Completes the Psychosocial Assessment for assigned patients as needed. This includes obtaining necessary data regarding the patient’s social and psychological history.

JUDGEMENT, DECISION MAKING AND INITIATIVE

• Demonstrates knowledge and proper use of equipment and supplies.
• Promotes and assists residents in developing self-help skills.

RELATIONSHIP WITH OTHERS

• Demonstrates a good rapport and cooperative working relationships with all members of the team; responds to co-workers with concern and promotes group morale.

QUALITY IMPROVEMENT

• Continually focuses on assigned tasks and seeks and implements improvements as necessary.
• Understands and demonstrates the safety program in all activities.
• Protects residents from behavior that could damage themselves or others.
• Practices universal precautions at all times.

PLANNING AND TIME UTILIZATION

• Completes and follows through with tasks and assignments, meeting expected deadlines.

ATTENDANCE AND RELIABILITY

• Understands and demonstrates knowledge of all policies associated with attendance.

PROFESSIONAL DEVELOPMENT

• Attends all assigned in-service education classes.
• Role models excellent professional practice.
• Always dresses appropriately and professionally.

 Essential Functions:

• Work closely with department director, psychiatric medical director, nurse manager and all clinical staff to meet the psychosocial needs of patients and families.
• Provides individual and group counseling, communicates with families and the patient’s authorized representatives, conservators, physicians and other health team members.
• Responsible for the mandated fire arms reporting to the California Department of Justice on admission for patients’ subject for reporting.
• Coordinates discharge planning, assists with advance directives, financial and legal issues and maintains documentation of services in the medical record.
• Provides group and individual counseling
• Assists physician with completion of legal paperwork/documentation, mindful of individual county time constraints
• Participates in the unit QAPI. Reviews indicators for social services on a pre-assigned basis, makes necessary corrections and makes recommendations for improvement.
• Assist patients with coordination of complaint/grievance/compliment process. Follows facility policy and procedure and coordinates with program director.
• Complete timely assessments and treatment planning
• Performs other duties as assigned.
• Theft and Loss- participates in the theft and loss program. Implements remedial actions as indicated.