Discharge Planner (CASAC, LMSW MSW)

Arms Acres Inc•Town of Hartwick, NY

About The Position

The Discharge Planner provides comprehensive clinical services with regard to discharge planning and maintains ongoing communication with the clinical team, regional contacts, families, legal representatives, and referral agencies. This role is integral to the team, especially for managing difficult patient placements and ensuring all discharge plans include necessary follow-ups, such as appointments with a Primary Care Physician (PCP). The position involves evaluating patient functioning, following up with patients who miss aftercare appointments, and offering referrals to appropriate programs. Documentation of patient progress and interventions is crucial, adhering to regulatory requirements. The Discharge Planner also maintains contact with referents to aid in treatment and discharge planning, assists with referral packets, and provides individual, group, and family treatment focused on discharge planning, relapse prevention, and life skills. Maintaining linkage agreements with other providers for aftercare services and participating in quality improvement activities are key responsibilities. The role also includes responding to facility emergencies, potentially supervising interns and volunteers, and maintaining professional competence through continuing education. Attendance at daily treatment planning and new patient orientations is required. The position may involve carrying a caseload of five or more patients, coordinating presentations from long-term facilities, and completing specific documentation like D/C plans and PAS 45 forms.

Requirements

High school diploma, general education degree (GED) or bachelor’s degree with CASAC certification or MSW, LMHC or master’s degree in related field.
CASAC-T accepted during the Orientation Period with the contingency of passing CASAC examination and CASAC successfully completed within a designated Period.

Responsibilities

Discharge planning for patients, ongoing communications with clinical team, referents, legal, family and referring agencies.
Oversee and participate as an integral part of the team for all difficult placements for patients.
Review and oversee all discharge plans for rehab patients for inclusion of appointments to PCP.
Provides/ensures comprehensive evaluation of patient's functioning as defined by facility policy and procedures.
Follow up with all AMA’s and no shows for aftercare through phone call and outreach. Offer referral to aftercare programs as needed. Documents patient progress and own interventions in case record. Need to remain within periods of regulatory requirements.
Maintains contact with referents to assist in treatment planning and discharge planning. This may include phone calls, collaborative calls with patients and collaborating with HIM dept. to ensure referral packets are sent.
Provides individual, group and family treatment (psycho-education, life skills) as identified in patient treatment plans in relation to discharge planning, relapse prevention and as requested by Program/Assistant director.
Maintain linkage agreements with other providers for aftercare services/placement.
Participates in quality improvement activities related to position and as requested by program director.
Responds to emergencies in the facility by following appropriate procedures for ensuring patient safety during emergency procedures.
Supervises interns and volunteers at the discretion of the director.
Maintains professional competence in discipline and treatment specialty areas through continuing education and supervision.
Attend daily treatment planning as well as new patient orientation directed by supervisor.
Participates in facility program and quality improvement activities.
May be responsible at times to carry a caseload of five or more patients dependent upon the needs of the facility.
Participates in Performance Initiatives.
Responsible with coordination of presentations from long-term facilities to our patients and staff.
Responsible for documentation requirements which will include D/C plan, PAS 45 and extended day LOCATDR’s.
Other duties as assigned by your supervisor.