- Initiates discharge plans for new and recent admissions.
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Provides all appropriate Notices of Action/ Notice of Decision documentation (when applicable).
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Responsible for all documentation necessary to complete an intake on Members newly enrolled and the Members currently existing with CODAC. This all includes: the Consent for Care and Treatment, Primary Care Physician Coordination forms and any Release of information forms, the entire CORE Assessment, ISP, Crisis Plan, Review of Progress, Legal and Substance abuse history, etc.
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Proactive discharge assessment by assessing the specific post discharge bio-psychosocial and medical needs of the Member prior to discharge. This process shall include the involvement and participation of the Member and representative(s), as applicable. The Member and representative(s) must be provided with the written discharge plan instructions and recommendations identifying resources, referrals, and possible interventions to meet the Member’s assessed and anticipated needs after discharge
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These requirements apply also to the ITDP (Inpatient Treatment and Discharge Plan), in accordance with the 9 AAC 21, Article 3.
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Communicates with members’ adult recovery team and site staff regarding member’s admission and appropriate discharge planning, transfers records to member’s site, as appropriate.
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Interacts with hospital discharge planner, inpatient prescribers, and other appropriate hospital staff regarding initiation and progress of discharge plans.
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Reviews and takes additional necessary steps to assure progress of discharge plans for CODAC members.
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Communicates with members’ adult recovery team and site staff regarding post-discharge needs, appointment schedules and other necessary supports. With this, the ability to coordinate and facilitate an adult recovery team meeting.
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Coordinates with medical records staff to obtain medical information from members’ records.
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In collaboration with members’ adult recovery team and site staff, prepares outpatient court ordered treatment plan for presentation to the courts.
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When appropriate, develops aftercare plan with members’ adult recovery team, prior to reentry into the community.
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Coordinates transition of care with the members’ adult recovery team and site staff.
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Ensures that hospital discharge summary is sent to appropriate site medical records department.
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Providing appropriate post discharge community referrals and resources or scheduling follow up appointments with the Member’s primary care provider and/or other outpatient healthcare providers within 7 days or sooner of discharge;
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Coordinates transfers to transitional sites, as appropriate.
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On call for hospital enrollments and arrives within 24 hours of notification.
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Performs other related duties in accordance with agency growth and changes.
