Discharge Planning Specialist

About the role

The Social Worker III performs and documents highly complex social services work including serving as a liaison between the patient, legally authorized representative, and others to assure ongoing care, treatment, and support through the use of person-centered practices. This position gathers information to assess the individual's support systems and service needs, including participation in interdisciplinary team meetings, as needed. This position may also engage in the assessment of individual’s rights and capacity to make decisions. This position designs and provides individual and group trainings to promote the exercise of rights and patient transition to include curriculum, materials, and case specific information. This position assists with the coordination of furloughs, transfers, transitions, and discharges, as needed. This position will focus on complex cases and concentrates on post discharge placement and support.

Responsibilities

• Attends work on a regular basis and may be asked to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned.
• Interviews and converses with individuals, legally authorized representatives, actively involved persons and agencies to create and maintain the individual’s social history through determination of what is important to the individual, gather background information needed to assess the individual’s support systems, and identify the individual’s psychosocial, economic, and physical needs, with updates as appropriate. Interview examples include during admission or prior to transition to a community placement.
• Oversees the communication and information exchange between the individual, legally authorized representative, actively involved person and agencies, as needed, and facility or treatment providers to assure ongoing care, treatment, and support to include maintaining open communication, providing required notification, participating in interdisciplinary team meetings as requested, obtaining necessary consents, and accessing external resources as needed.
• Counsels and provides assistance to individuals, legally authorized representatives, and actively involved persons regarding community placement issues, living options discussions, end-of-life planning, and rights in accordance with state and federal laws and regulations and state and state hospital policies.
• Oversees transfers, transitions, furloughs, and community placement discharges by involving the patient, family/significant others (with consent), as well as the committing court, and Local Mental Health Authority (LMHA), for an orderly discharge that includes a referral for continued treatment and services as needed and medication and personal possessions through the use of person-centered practices. Examples include: coordinating and conducting tours of identified discharge options for individuals and families, engagement and communication with state and judicial systems as well as facility or treatment providers, providing information to the local authority to assist in obtaining required documents for discharge planning including certified birth certificates, ISD records and social security cards and coordinating with the receiving facility for individuals transferring within the State Hospital system to include transportation and the transfer of patient information, personal possessions, medication, etc.
• Designs and conducts individual and group training to explore and promote exercise of rights, development of decision-making, person centered thinking and self-advocacy skills. Develops and presents curriculum and training materials designed to support patients to a wide array of interested parties, patients, and stakeholders.
• Participates in and may be responsible for the facilitation of discharge program meetings and internal/external work groups. Actively engaged in the utilization of existing resources as well as in the identification of potential service gaps.
• May assign and oversee the work, time, and travel of Social Worker I and II positions and social work students to include, interviewing and hiring to fill vacancies, training of new staff and current staff as needed.

Requirements

One year of experience working directly with persons with mental, social, or substance use disorders.

Qualifications

Must have and maintain State of Texas Social Workers License (LBSW or above) OR must obtain license within six months of hire.

Skills and Abilities

• Knowledge of human growth and development, behavioral and mental health, developmental and emotional components of physical illness, individuals with intellectual and developmental disabilities, social work standards for case management; facility and community resources, and the principles, methods and theories used to practice as a social worker.
• Knowledge of community resources to support the discharge of state hospital patients with high/complex needs.
• Knowledge of State Hospital discharge policies and procedures.
• Skill and ability to assign and supervise the work of others.
• Skill in accountability for assigned property with limited financial responsibilities.
• Skills in interviewing, assessment, planning, intervention, evaluation, case management, mediation, counseling, information and referral, problem solving, supervision, consultation, and advocacy.
• Ability to be creative and work collaboratively with others on behalf of patients discharging from state hospitals

Benefits

Comprehensive benefits package including 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more.

Pay

$5,746.66 - $7,253.83 per month

Schedule

Day Shift