The Behavioral Health Discharge Planner is responsible for leading and coordinating the discharge planning process for patients admitted to an inpatient psychiatric setting. This role ensures continuity of care, reduces risk of readmission, and promotes patient stability by developing comprehensive, individualized discharge plans that address clinical, psychosocial, environmental, and financial needs. The Discharge Planner works as an integral member of the interdisciplinary treatment team and serves as a Liaison between the hospital, community-based providers, patients, and families. This position requires strong clinical judgment, knowledge of behavioral health systems of care, and adherence to regulatory and accreditation standards (e.g., CMS Conditions of Participation, Joint Commission).

Discharge Planning & Care Coordination

• Initiate discharge planning at the time of admission and reassess throughout the patient’s stay
• Complete or contribute to discharge planning assessments, including psychosocial needs, barriers, and risk factors, within scope of practice
• Develop, implement, and update individualized discharge plans in collaboration with the treatment team
• Identify and address barriers to discharge, including housing, transportation, insurance, and access to medications/services
• Identify appropriate levels of care post-discharge (e.g., outpatient therapy, intensive outpatient programs (IOP), partial hospitalization programs (PHP), residential treatment, or long-term care)
• Coordinate transitions to community-based services
• Ensure continuity of psychiatric care, including medication management and therapy services
• Ensure patients are provided with freedom of choice in selecting post-discharge providers and services
• Ensure follow-up appointments are scheduled within recommended timeframes (e.g., within 7 days of discharge)

Clinical & Risk Management

• Assess patient readiness for discharge, including evaluation of safety, stability, and support systems
• Identify high-risk patients (e.g., suicidality, homelessness, substance use, frequent readmissions) and implement enhanced discharge planning Interventions
• Collaborate with clinical staff to ensure discharge plans align with treatment goals and risk mitigation strategies

Interdisciplinary Collaboration

• Participate in daily treatment team meetings, case conferences, and utilization reviews
• Collaborate with psychiatrists, nurses, therapists, and other clinical staff to ensure coordinated care
• Serve as a central point of communication for discharge-related planning and problem-solving

Patient, Family & Caregiver Engagement

• Educate patients and families on discharge plans and aftercare services
• Involve support systems in discharge planning when appropriate
• Provide support around transitions, barriers to care, and community reintegration

Community Resource Coordination

• Maintain up-to-date knowledge of community resources, including mental health providers, housing programs, substance use treatment services, and social services
• Coordinate referrals to community agencies and ensure warm handoffs whenever possible

Documentation & Compliance

• Document all discharge planning activities in the medical record in conformity with hospital policy and regulatory standards
• Ensure documentation supports medical necessity, level of care decisions, and continuity planning
• Comply with all applicable regulations, including CMS Conditions of Participation, Joint Commission standards, HIPAA, and state-specific requirements
• Participate in audits, quality improvement initiatives, and performance metrics related to discharge planning and readmissions

The intent of this job description is to provide a representative summary of the major duties and responsibilities perform by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.