MSW Discharge Planning

National Psychiatric Care and Rehabilitation Services•Ashland, CA

About The Position

Master Social Worker (MSW) is responsible for coordinating discharge planning and facilitating community outreach for individuals transitioning from a Mental Health Rehabilitation Center (MHRC) to the community. This role involves providing clinical support, case management, and counseling services to patients, ensuring a smooth transition to less restrictive settings, and connecting individuals with community resources and support services. The MSW will collaborate with interdisciplinary teams, engage with families, and support patients in reintegrating into their communities while maintaining continuity of care and promoting long-term recovery.

Requirements

Master’s Degree in Social Work (MSW) from an accredited school of social work (required).
Active California LCSW License (required).
At least 2-3 years of clinical experience working with individuals with severe mental health conditions in a rehabilitation or treatment setting.
Case Management: Strong skills in case management, including coordinating services, managing multiple referrals, and ensuring continuity of care across various service providers.
Communication: Excellent verbal and written communication skills. Ability to clearly document patient progress and treatment plans and to advocate for patients within a multidisciplinary team and external agencies.
Clinical Skills: Proficiency in providing individual therapy, group therapy, and crisis intervention. Ability to work effectively with patients in various emotional states.
Cultural Competence: Ability to work effectively with diverse populations, demonstrating sensitivity to cultural, socioeconomic, and ethnic differences.
Problem-Solving and Resourcefulness: Ability to creatively address challenges in the discharge process and community reintegration, ensuring that patients’ needs are met with available resources.
Collaborative Mindset: Ability to collaborate effectively with an interdisciplinary team and external agencies to support patient outcomes.
Physical Requirements: Ability to sit or stand for long periods and interact with patients and team members. Ability to lift up to 20 pounds occasionally (e.g., carrying case files, supplies, etc.). Ability to travel to community agencies or patient homes for outreach and coordination of services

Nice To Haves

Experience in discharge planning and community outreach within a mental health setting is highly preferred.
Knowledge of the Lanterman-Petris-Short (LPS) Act and other California-specific mental health regulations is a plus.

Responsibilities

Discharge Planning and Coordination
Conduct Comprehensive Assessments
Prepare patients for discharge by assessing their readiness, treatment progress, and any continuing care needs.
Develop Discharge Plans
Create and implement detailed, individualized discharge plans in collaboration with patients, their families, and the interdisciplinary treatment team.
Coordinate Care Transitions
Work with external service providers, such as outpatient clinics, psychiatrists, case managers, housing programs, and social services, to ensure continuity of care upon discharge.
Advocate for Patients
Act as an advocate for patients by ensuring they have access to necessary resources, including health services, transportation, housing, vocational services, and other community supports to aid in their reintegration.
Monitor Post-Discharge Success
Follow up with patients post-discharge to assess their progress and ensure that their needs are being met in the community.
Community Outreach and Resource Development
Build Community Relationships
Develop and maintain relationships with local community agencies, service providers, and organizations that can support patients in their recovery journey (e.g., housing programs, vocational training, social services, and support groups).
Develop Resource Networks
Identify and cultivate partnerships with local resources and agencies to ensure patients have access to a wide range of services.
Provide Psychoeducation
Lead community outreach efforts to educate local organizations, businesses, and support networks about mental health issues, available resources, and the importance of supporting individuals with mental health challenges in their community.
Create Resource Directories
Maintain and update a comprehensive resource directory for patients, families, and the care team, detailing available services such as housing, employment, educational programs, and mental health services.
Clinical Support and Counseling
Provide Therapy and Counseling
Offer individual and group therapy to patients as part of their treatment program, focusing on adjustment to community living, coping skills, self-management, and other issues pertinent to discharge and reintegration.
Crisis Intervention
Assist patients in managing emotional or behavioral crises, including providing immediate support and coordinating appropriate interventions, such as hospitalization or emergency services when needed.
Support Patients in Transition
Provide ongoing therapeutic support during the discharge planning process, addressing the emotional and psychological barriers patients may face as they transition from inpatient care to community living.
Collaboration with Interdisciplinary Team
Collaborate with Healthcare Providers
Work closely with psychiatrists, nurses, mental health technicians, and other professionals on the interdisciplinary team to ensure that the discharge plan aligns with patients’ clinical needs and treatment goals.
Family Involvement
Involve families and support systems in discharge planning and provide family therapy, psychoeducation, and counseling to prepare them for their loved one’s transition into the community.
Document and Report
Maintain accurate and comprehensive documentation of discharge plans, community resources, therapy notes, and any other relevant patient information in accordance with facility and regulatory guidelines (e.g., HIPAA, California Department of Health standards).
Quality Improvement and Compliance
Monitor Outcomes
Regularly review patient outcomes related to discharge and community integration.
Adhere to Regulations
Ensure compliance with state and federal regulations, including the Lanterman-Petris-Short Act (LPS) and any other applicable California mental health regulations, in all aspects of discharge planning and community outreach.
Report to Supervisors
Provide regular updates to supervisors regarding progress, challenges, and any resource gaps or issues that may hinder patient reintegration into the community.