Care Coordinator

New Living Health Care Services provides community-based mental health, substance use, and primary care treatment, with many of our patients presenting with co-occurring mental health needs. This full-time Licensed Practical Nurse plays a dual role: leading discharge and transition planning for clients moving between psychiatric hospitals, detox and residential treatment facilities, medical hospitals, and other inpatient settings back into the community, while also serving as an in-house clinical resource, performing blood draws and other lab specimen collection, and handling day-to-day in-house patient requests. A key goal of this role is to support patient retention in primary care, ensuring that clients being treated for mental health and substance use needs also stay engaged with and connected to their ongoing primary care services. The LPN maintains a primary caseload, provides direct patient care to consumers, leads discharge and transition planning efforts across psychiatric, substance use, and medical settings, and in collaboration with the transdisciplinary team, coordinates care for all clients in a compassionate and responsible manner.

RESPONSIBILITIES

• Serve as the primary point of contact for coordinating client discharges from psychiatric hospitals, detox facilities, substance use residential/inpatient programs, medical hospitals, and other inpatient settings back into the community;
• Communicate proactively with hospital psychiatric units, detox and substance use treatment programs, case managers, discharge planners, and medical staff to obtain timely notification of admissions, treatment updates, and anticipated discharge dates;
• Attend or participate in discharge planning meetings and treatment team huddles to advocate for client needs and ensure a safe, well-coordinated transition, with particular attention to psychiatric stability and relapse/overdose risk;
• Develop and implement individualized discharge/transition plans in collaboration with the client, ACT team, and outside providers, addressing housing, psychiatric medication continuity, substance use treatment step-down (e.g., detox to residential to outpatient/IOP), relapse prevention planning, follow-up appointments, and support services;
• Complete medication reconciliation at discharge, including psychiatric medications and medication-assisted treatment (MAT/MOUD) such as buprenorphine, methadone, or naltrexone, and ensure prescriptions are filled and understood by the client prior to leaving the facility;
• Coordinate transportation, housing arrangements (including sober living/recovery housing when indicated), and immediate post-discharge needs to reduce risk of readmission, relapse, overdose, or homelessness;
• Schedule and confirm follow-up appointments with psychiatric providers, substance use treatment providers, PCPs, and specialists within required post-discharge timeframes;
• Conduct in-person or telephonic follow-up with clients within 24-72 hours of discharge to monitor psychiatric stability, sobriety, medication adherence, withdrawal symptoms, and identify emerging concerns or relapse warning signs;
• Provide overdose prevention education and coordinate access to naloxone (Narcan) for clients and their support networks as part of discharge planning;
• Maintain accurate, timely documentation of all discharge planning activities, including discharge summaries, transition notes, and follow-up contacts, in the electronic health record;
• Track psychiatric hospitalizations, detox admissions, and discharges across the caseload and report trends, gaps, or recurring issues to the ACT Team RN and Team Leader;
• Administer IM injections, including long-acting injectable psychiatric medications, and provide direct nursing care to clients as needed, consistent with LPN scope of practice;
• Collaborate with the office-based LPN and Team RN on medication delivery, packing, and administration schedules, including coordination with MAT/MOUD prescribers and pharmacies;
• Maintain and update each client's medical profile, PCP and psychiatric provider information, vitals, diagnoses, and record of recent medical, psychiatric, and substance use treatment visits;
• Provide health education to clients and caregivers regarding psychiatric diagnoses, substance use disorders, medications, and self-management following discharge;
• Advocate for clients in accessing and navigating the mental health and substance use treatment systems during and after hospitalization;
• Participate in facilitating appropriate psychiatric hospitalizations, detox admissions, crisis interventions, and referrals when re-admission or a higher level of care is clinically indicated;
• Serve as liaison between the team and outside providers, including psychiatric hospitals, detox and substance use treatment programs, pharmacies, and provider relations contacts;
• Perform blood draws (phlebotomy) and collect other lab specimens from patients on-site, ensuring proper labeling, handling, and timely delivery to the lab;
• Serve as an in-house clinical resource, handling day-to-day walk-in and same-day patient requests (vitals checks, injections, basic triage, and other nursing needs);
• Support patient retention in primary care by proactively following up with clients to schedule and keep primary care appointments, closing gaps between behavioral health/substance use visits and primary care visits;
• Track and follow up on overdue primary care visits, annual wellness exams, and preventive screenings for clients on the caseload;
• Generate 4.5 hours of Medicaid billable services each work day;
• Participate in on-call rotation;
• Perform other related work as assigned.

QUALIFICATIONS

Required

• EDUCATION - Must have successfully completed all education and training requirements leading to and graduated from an accredited national, state or military equivalent school for Practical Nursing.
• LICENSE - Must have and maintain throughout course of contract, a current, active, valid, unrestricted license (with no limitations, stipulations or pending adverse actions) to practice as a Licensed Practical Nurse (LPN) from a US jurisdiction. License must be recognized and accepted by the DC Department of Health in accordance with governing regulations.
• Patience, creativity, flexibility, compassion, and sensitivity to persons with disabilities and other minority populations;
• Excellent communication, writing, and computer skills, particularly for coordinating with psychiatric hospital and substance use treatment staff and completing timely discharge documentation;
• Driver's License required.

Knowledge

• As appropriate within established procedures, protocols, and scope of practice, must have understanding of and ability to correctly utilize and/or apply: medical terminology, anatomy and physiology, psychology, pharmacology, medical ethics and legal concepts, clinical procedures, and patient care;
• Mental illness and substance use disorders, including common psychiatric diagnoses, withdrawal syndromes, signs of intoxication/relapse, and the levels of care within the substance use treatment continuum (detox, residential, IOP, outpatient);
• Psychiatric medications and medication-assisted treatment (MAT/MOUD), including buprenorphine, methadone, and naltrexone, their side effects, and adherence support strategies;
• Overdose recognition and response, including naloxone (Narcan) administration and education;
• Phlebotomy and proper specimen collection, labeling, and handling procedures;
• Emergency medical treatment, including cardiopulmonary resuscitation, specimen collection, diagnostic testing;
• Preparation and administration of oral and parenteral (excluding IV) medications, including long-acting injectable psychiatric medications, vaccination procedures, mechanisms of anaphylaxis and shock and their treatment;
• Prescription drugs and their administration, including medication reconciliation at transitions of care;
• Operating and maintaining therapeutic equipment, risk management, medical contingency operations;
• Computer operations in the use of basic word processing, data entry, and automated medical records/EHR systems.

Experience

• Experience performing care and treatment of patients; experience working in a team-based setting; operating and maintaining therapeutic equipment; properly administering oral and parenteral medications; conducting paraprofessional portions of physical examinations; or assisting in medical treatment of patients in accordance with established procedures and protocols, within the LPN scope of practice.

Preferred

• 2 years of work experience in behavioral health, substance use treatment, social services, supported housing, and/or persons with psychiatric disabilities;
• Experience in psychiatric or substance use hospital/detox discharge planning, care transitions, case management, or utilization review;
• Experience supporting clients on medication-assisted treatment (MAT/MOUD) or in co-occurring disorder treatment settings;
• Has practiced as an LPN performing hands-on patient care in a behavioral health or outpatient clinical setting for at least 12 months within the past 24 months;
• Familiarity with Medicaid billable note writing;
• Bilingual English/Spanish a plus.

BENEFITS

• Health Insurance (singles, partner, and family coverage offered)
• Dental & Vision insurance
• Paid Time Off accrued at 3.3 hours per pay period