Community Based Discharge Coordinator

Job Description

Job Title: Collaborative Bridges Community-Based Discharge Coordinator 

Reports To: Collaborative Bridges Supervisor

Purpose:

The purpose of this position is to stabilize patients after they have experienced a crisis episode upon discharge from emergency room and inpatient psychiatric units. This Community-Based therapist is responsible for the provision of community transition services and brief therapy for youth and adult patients 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 hospitals and provide support with therapy and care coordination services until linked to long term community providers or consumer needs are resolved.

For more information on our innovative model of care:

Interview with Collaborative Bridges leaderships on WGN

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. Complete Follow-up to Hospitalization screenings for consumers discharging from inpatient psychiatric units and emergency room settings for substance abuse and mental health presentation. 
4. Assist with ensuring hospital discharge recommendations are understand by consumer and followed through with by the patient. 
5. Ensure interventions are recovery‐oriented, culturally congruent and developmentally appropriate
6. Understand risk assessment, safety planning, and de-escalation interventions, integrating  Zero Suicide/Suicide Safer Care principles.
7. Engage natural and family support to strengthen the individual's participation and engagement.
8. Deliver services within hospital, office, and community settings. 
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.
14. Maintain effective communication and coordination with paired hospital and participate in hospital meetings.

Minimum Qualifications:

1. Graduate Degree in Behavioral Health field and a minimum of two year of related experience
2. Familiarity and comfortability doing community work in the Westside of Chicago. 
3. Personal vehicle, valid drivers license, insurable driving record and vehicle insurance

Competencies (Minimum Skills, Knowledge, and Experience):

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