Discharge Planner

Job Description

Job Description

Job Summary

The Discharge Planner will be responsible for developing comprehensive discharge plans that address the mental health and substance use needs of clients, ensuring continuity of care and connection to community resources. This role includes assessing an individual’s readiness, coordinating post-discharge services, and collaborating with internal and external providers. The planner will educate individuals and families on available support and ensure all documentation meets regulatory standards.

​ This is a 24 / 7 facility with shifts available across all hours. Compensation is based on experience.

Essential Functions

• Conduct thorough assessments of individual’s mental health, substance use, medical, and social needs to create individualized discharge plans
• Collaborate with the treatment team, including physicians, therapists, social workers, and nurses, to ensure a holistic understanding of the patient's needs
• Evaluate the individual’s readiness for discharge and address any barriers to a successful transition
• Identify and arrange appropriate post-discharge resources, including outpatient therapy, substance use treatment programs, housing, support groups, vocational rehabilitation, and medical follow-up
• Coordinate with community resources, mental health agencies, addiction recovery programs, and other support services
• Develop a discharge plan that includes scheduling of follow-up appointments, transportation assistance, and ongoing communication with external providers
• Provide education and guidance to individuals and families regarding the discharge plan, community resources, and strategies for managing mental health and substance use challenges
• Ensure individuals and their families understand the importance of follow-up care and provide instructions for accessing services
• Maintain detailed and accurate documentation of discharge planning activities, including assessments, care coordination efforts, and any referrals made
• Ensure all discharge planning follows federal, state, and local regulations, as well as organizational policies
• Monitor individual progress post-discharge and adjust plans as necessary
• Act as a liaison between individuals, families, providers, and community resources
• Participate in multidisciplinary team meetings to discuss discharge options and contribute to the treatment planning process
• Provide crisis intervention services as needed to support the immediate needs of individuals during the discharge process
• Other duties as assigned

Job Requirements and Qualifications

Education

Training Requirements (licenses, programs, or certificates) :

CPR / BLS

Experience Requirements :

Job Specific Competencies / Skills :

Knowledge Requirements :

Oakland Community Health Network’s Core Competencies :

Additional Information

(Travel required, physical requirements, on-call schedules, etc.) :

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees' differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.