Hospital Transition Coordinator - full-time - 1st shift - Mon-Fri

Position Summary

This position provides hospital-to-community transition services, including behavioral health services provided by CMHA, to patients enrolled in the Behavioral Health Home and other programming within the organization within identified best practice timeframes. It involves maintaining positive working relationships with hospital inpatient units and emergency departments to develop and maintain systems to notify CMHA of agency client admissions and pending discharges. The role also engages individuals and their families in discharge planning and ensures patient discharge needs are met.

Essential Responsibilities

• Provides hospital-to-community transition services, including behavioral health services provided by CMHA, to patients enrolled in the agency’s Behavioral Health Home Program and other agency programming within timeframes specified by contract.
• Maintains good working relationships with hospital inpatient units and emergency departments to develop and maintain systems, including HIT/technology related systems, to notify CMHA of agency client admissions and pending discharges.
• Engages clients upon admission to the hospital and visits regularly to assist with discharge planning.
• Engages clients and their families in discharge planning and by providing needed resources and tools to ensure a smooth transition to community services.
• Upon discharge, ensures scheduling of follow up appointments, medication reconciliation, schedules transportation and coordinates other needed services.
• Responsible for coordination of admission and discharge records requested from agency and from area hospitals following inpatient hospital stays and/or emergency department visits.
• Responsible for tracking hospital admissions and discharges within the EMR and for scheduling appointments for clients through coordination with front desk and program area leaders.
• Obtain weekly status on clients in the hospital and prepare reports for weekly clinical oversight meeting.
• Makes weekly monitoring of pending discharges on a weekly basis for clinicians/medical staff to alert staff that clients need to receive follow up.
• Ensures that clients receive all necessary services upon discharge.
• Develops new relationships with hospitals CMHA does not have a working relationship with to ensure our clients are being transitioned successfully to community.
• Affairs with state hospital admission unit and attends Community Care Team Meetings (CCT) with the local hospitals being an active member representing the agency.