Discharge Care Coordinator - HPH Collaborative Bridges Grant

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.

Essential

Duties: and Responsibilities:

• 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 understand by consumer and followed through with by the patient. ‘ 4.
• Coordinate discharge planning with community-based Collaborative Bridges stabilization team.
• 5.
• Act as liaison to 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 the 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 identifying 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.