Disposition Planner PRN

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Day (United States of America)

The Care Coordinator is responsible for coordination of care for every patient from the time of admission until discharge from the hospital to the next level of care. This includes psychosocial and functional status assessment, individual, group and family therapy sessions, transitional care planning, patient advocacy, education for the patient/family, and assuring a safe and adequate discharge plan depending upon the patient’s needs and resources.

Collaborates with all team members to provide a comprehensive assessment of the patient’s plan of care, goal/outcome attainment and continued care needs.

Clinical Assessment and Care Planning (including Developmental Needs)

• Initiate and interpret thorough clinical assessments. Demonstrates skill in patient assessment that takes patient’s age and developmental needs into consideration when developing discharge and resource plans.
• Determine current mental status, history of present illness, financial status, living situation, support system and risk of harm to self or others and other information required according to the accrediting bodies.
• Verbalizes understanding of developmental needs of adults and geriatric populations; is sensitive to these issues in assessment and care planning for patients and families.
• Demonstrates skill in assisting families with placement of patients in supervised living arrangements.
• Based upon the initial and ongoing assessments, recommends the appropriate level of care and facilitates access to those services, i.e., further inpatient admission, outpatient services, residential placement.
• Consult with physicians, providers and other members of the treatment team regarding recommendations for further behavioral health services.
• Review criteria and scope of services with the patient/guardian to ensure comprehension of program services available and provide recommendations.
• Recognizes indicators of suspected child/adolescent/disabled person/elder abuse and neglect, and follows mandated reporting policies and regulations.
• Documents psychosocial assessment information on appropriate electronic medical record screens or downtime paperwork.
• Partners with patient and family/support system to develop treatment plan based on patient/family needs, i.e., education, support, case management.

Disposition Planning/Patient Education/Therapy Services

• Implements discharge planning in an appropriate, timely, and efficient manner.
• Attends multidisciplinary team meetings and care plan meetings to assist with disposition planning needs.
• Serves as patient advocate in the recovery/healing process.
• Provides resource information for patient/family to make appropriate plans for follow‑up care.
• Understands eligibility processes and criteria for both private and public local, state, and federal resources.
• Completes necessary paperwork (including continuing care plan) and makes arrangements for transfer to appropriate level of care.
• Evaluates the effectiveness of the patient’s plan of care and makes revisions as needed.
• Provides education and counseling for patients and families; provides individual and group therapy for patients; documents interventions.
• Develops and maintains productive working relationships with community agencies, nursing homes, personal care homes, and other resource centers.
• Demonstrates working knowledge of community resources.
• Responds to requests from hospital staff, provider offices, and community entities to provide resource information and education.
• Provides financial needs assessment and makes appropriate referrals for patients in need of assistance.
• Provides follow‑up for…