LPN - Discharge Planning & In-House Patient Care (Mental Health

New Living Health Care Services provides community-based mental health, substance use, and primary care treatment, with many of our patients presenting with co-occurring mental health needs. This full-time Licensed Practical Nurse plays a dual role: leading discharge and transition planning for clients moving between psychiatric hospitals, detox and residential treatment facilities, medical hospitals, and other inpatient settings back into the community, while also serving as an in-house clinical resource, performing blood draws and other lab specimen collection, and handling day-to-day in-house patient requests.

A key goal of this role is to support patient retention in primary care, ensuring that clients being treated for mental health and substance use needs also stay engaged with and connected to their ongoing primary care services. The LPN maintains a primary caseload, provides direct patient care to consumers, leads discharge and transition planning efforts across psychiatric, substance use, and medical settings, and in collaboration with the transdisciplinary team, coordinates care for all clients in a compassionate and responsible manner.

• Serve as the primary point of contact for coordinating client discharges from psychiatric hospitals, detox facilities, substance use residential/inpatient programs, medical hospitals, and other inpatient settings back into the community;
• Communicate proactively with hospital psychiatric units, detox and substance use treatment programs, case managers, discharge planners, and medical staff to obtain timely notification of admissions, treatment updates, and anticipated discharge dates;
• Attend or participate in discharge planning meetings and treatment team huddles to advocate for client needs and ensure a safe, well-coordinated transition, with particular attention to psychiatric stability and relapse/overdose risk;
• Develop and implement individualized discharge/transition plans in collaboration with the client, ACT team, and outside providers, addressing housing, psychiatric medication continuity, substance use treatment step-down (e.g., detox to residential to outpatient/IOP), relapse prevention planning, follow-up appointments, and support services;
• Complete medication reconciliation at discharge, including psychiatric medications and medication-assisted treatment (MAT/MOUD) such as buprenorphine, methadone, or naltrexone, and ensure prescriptions are filled and understood by the client prior to leaving the facility;
• Coordinate transportation, housing arrangements (including sober living/recovery housing when indicated), and immediate post-discharge needs to reduce risk of readmission, relapse, overdose, or homelessness;
• Schedule and confirm follow-up appointments with psychiatric providers, substance use treatment providers, PCPs, and specialists within required post-discharge time frames;
• Conduct in-person or telephonic follow-up with clients within 24-72 hours of discharge to monitor psychiatric stability, sobriety, medication adherence, withdrawal symptoms, and identify emerging concerns or relapse warning signs;
• Provide overdose prevention education and coordinate access to naloxone (Narcan) for clients and their support networks as part of discharge planning;
• Maintain accurate, timely documentation of all discharge planning activities, including discharge summaries, transition notes, and follow-up contacts, in the electronic health record;
• Track psychiatric hospitalizations, detox admissions, and discharges across the caseload and report trends, gaps, or recurring issues to the ACT Team RN and Team Leader;
• Administer IM injections, including long-acting injectable psychiatric medications, and provide direct nursing care to clients as needed, consistent with LPN scope of practice;
• Collaborate with the office-based LPN and Team RN on medication delivery, packing, and administration schedules, including coordination with MAT/MOUD prescribers and pharmacies;
• Maintain and update each client's medical profile, PCP and psychiatric provider information, vitals, diagnoses, and record of recent medical, psychiatric, and substance use treatment…