Hospital Continuity of Care Worker
This position is responsible to daily review new admissions to state hospitals and other Center funded hospital beds to begin the continuity of care process for Center customers in the psychiatric hospitals. The COC worker will work with hospital customers and their hospital treatment teams in order to identify the precipitating factors leading to the hospital admission in order to participate in aftercare planning. The COC worker will use motivational interviewing skills to engage customers in mental health and substance abuse aftercare planning and will encourage family involvement in aftercare planning. This position will be responsible to alert Center treatment staff about hospital discharges, their aftercare needs and about risk factors for readmission.
COC worker will be responsible to coordinate aftercare, face to face appointments of all customers who are discharged from center-funded bed in a psychiatric facility. Aftercare services provided are immediate and intensive to avoid hospital readmission. The COC worker will be responsible for providing face to face aftercare services within 7 days to persons who are hospitalized on their own insurance, insuring all aftercare needs are assessed and appropriate referrals are made. This position will assist discharging customers to transition home, respite, placements or other shelter at discharge. COC worker will be responsible to follow up cases that miss their aftercare in order to reengage them in aftercare. The position will provide case management and/or skills training services to hospital discharges that have not yet completed admission to Center services. These in home services will target the psycho-social issues and/or precipitating factors that led to the hospital admission including substance abuse, homelessness, employment, medical, etc. COC worker will also provide back up for the Assessment and Referral Department.
Betty Hardwick Center is a Tobacco Free Campus for all employees.
Requires a Texas License as an LCSW or LPC; Must be eligible to be certified as a Qualified Mental Health Professional. Prefer previous mental health work experience with adult and child mental health consumers and familiarity with psychiatric hospitalization criteria. Experience in inpatient utilization review/management is a plus. Must possess a valid Texas Drivers License and be an insurable driver.