Discharge Planner

The Community Service Board of Middle Georgia is dedicated to providing those we serve with quality innovative behavioral healthcare in a recovery-based environment. CSB of Middle Georgia is recognized as a state leader in comprehensive behavioral healthcare providing integrated cost-effective services. CSB of Middle Georgia is located in Dublin, Georgia, and the agency currently serves residents of Bleckley, Dodge, Johnson, Laurens, Montgomery, Pulaski, Telfair, Treutlen, Wheeler, and Wilcox counties in Georgia;

and in our Ogeechee Behavioral Health Division, serving residents of Burke, Emanuel, Glascock, Jefferson, Jenkins, and Screven counties in Georgia. We value Quality, Professionalism, Person-Centered, Recovery, Teamwork, Improvement, Accountability, Management of Practicing Information, Wellness, and Financial Stability.

LOCATION:
Dublin, GA

Discharge Planner at our new Behavioral Health Crisis Center (BHCC) in Dublin, GA. This State-of-the-art new facility features 40 total patient beds, including 24 crisis stabilization beds and 16 temporary observation beds, offering both voluntary and involuntary patients access to safe, secure, and compassionate care. This facility will provide critical support and stabilization services for individuals experiencing behavioral health crises in a safe, structured environment where individuals can begin their journey towards healing and recovery.

• Initiate case management services at admission by interviewing individuals to gather history of prior treatment, current services, and existing case management involvement.
• Collect and document comprehensive information on each individual’s needs, strengths, preferences, and access to basic resources. Provide ongoing documentation reflecting how identified needs and barriers are addressed throughout the stay.
• Collaborate with external providers and agencies to coordinate care, obtain treatment history, and ensure continuity of services. Secure appropriate Releases of Information (ROI) for all communications.
• Maintain consistent communication with individuals and their families/support systems (with consent) to develop and facilitate safe, effective discharge plans with clearly defined supports.
• Identify and address barriers to care, including access to medications, transportation, appointments, financial limitations, and follow-up services. Ensure all interventions and resolutions are thoroughly documented.
• Coordinate referrals and admissions to appropriate levels of care, including long-term care facilities, outpatient services, and community support programs. Assist with insurance initiation (e.g., through Hope Dealers) when needed to support placement.
• Arrange and confirm follow-up appointments prior to discharge, ensuring individuals are informed of all aftercare plans, including appointment details, locations, and any open-access hours.
• Prepare, complete, and review interdisciplinary discharge summaries, ensuring all required elements are included (clinical benchmarks, health conditions, referrals, community resources, follow-up care, and 988/crisis information). Ensure all documentation is signed, finalized, and properly filed.
• Review discharge plans with individuals prior to discharge, providing a clear overview of aftercare services and expectations.
• Communicate suicide risk status (high/moderate) and other critical clinical information to receiving providers to ensure safe transitions of care.
• Coordinate and arrange transportation for individuals upon discharge, and assist with transport when necessary.
• Maintain accurate and up-to-date records in the electronic health system (e.g., Netsmart), including verified contact information and completed ROI documentation for follow-up communication.
• Conduct follow-up outreach within 7 days of discharge (minimum of three attempts), with additional documentation requirements for individuals identified as high or moderate suicide risk. Maintain a log of follow-up attempts to support continuity of care.
• Assist with Level of Care (LOC) submissions, service orders, and suicide risk alerts as required.
• Ensure all treatment plan…