Detailed job description and main responsibilities

The Complex Discharge Nurse is a senior registered nurse responsible for coordinating, facilitating and overseeing the discharge planning process for patients with complex health and social care needs. The post holder will work collaboratively with patients, their families, carers and multidisciplinary teams to ensure safe, timely and effective discharge from hospital, whilst reducing avoidable delays and improving patient outcomes. The role requires proactive case management, excellent communication skills and the ability to coordinate complex discharge pathways across health and social care systems. The post holder will act as an expert resource for ward teams, supporting the delivery of Home First and Discharge to Assess principles and ensuring patient-centred discharge planning is embedded throughout the patient journey.

Main Responsibilities

Clinical and Discharge Coordination

• Coordinate and manage the discharge planning process for patients with complex health, social care and continuing care needs from admission through to discharge.
• Ensure all patients have a documented discharge plan, Expected Date of Discharge (EDD) and identified actions to support timely discharge.
• Undertake comprehensive assessments and coordinate discharge pathways for patients requiring complex packages of care, rehabilitation, nursing home placement, Continuing Healthcare Fast Track, end-of-life care services and other specialist discharge pathways.
• Identify, monitor and proactively manage barriers to discharge, escalating delays appropriately to maintain patient flow and minimise unnecessary hospital stays.
• Ensure discharge plans reflect patient wishes, strengths, individual needs, safeguarding requirements and the least restrictive care option available.
• Support the implementation of national discharge guidance, Home First principles and Discharge to Assess pathways.

Patient, Family and Carer Engagement

• Act as the named discharge coordinator for patients with complex discharge needs, providing a consistent point of contact throughout their hospital stay.
• Involve patients, relatives and carers in discharge planning and decision-making, ensuring they receive clear and timely information regarding discharge arrangements and available support services.
• Facilitate discussions relating to discharge planning, future care needs and care options, maintaining a patient-centred approach at all times.
• Support patients and families to understand discharge processes and set realistic expectations regarding discharge planning and community support.

Multidisciplinary Team Working

• Work in close partnership with medical teams, therapists, social workers, mental health practitioners, community providers and local authority colleagues to facilitate seamless discharge planning.
• Lead and contribute to multidisciplinary team meetings, board rounds and discharge planning discussions to progress patient discharges and resolve delays.
• Develop and maintain effective working relationships with internal and external stakeholders to support integrated discharge pathways and improve patient outcomes.
• Liaise with community health services, social care teams, care providers and voluntary sector organisations to ensure continuity of care following discharge.

Discharge Pathway Management

• Coordinate referrals to community health services, social care, intermediate care, care home placements and other support services to ensure appropriate arrangements are in place prior to discharge.
• Facilitate Continuing Healthcare, Fast Track, nursing home, residential care and other complex discharge assessments in line with local and national guidance.
• Ensure equipment, transport, medication, funding approvals and support services are arranged and confirmed prior to discharge where required.
• Monitor and track patient progress through discharge pathways, ensuring actions are completed within agreed timescales.
• Escalate delays and operational challenges affecting patient flow through the appropriate management and governance structures.

Leadership, Education and Service Improvement

• Provide specialist advice, guidance and support to ward staff regarding discharge planning processes, policy requirements and complex discharge pathways.
• Promote best practice and support staff in developing knowledge and skills relating to discharge planning and patient flow management.
• Act as a role model for person-centred discharge planning and integrated working across organisational boundaries.
• Participate in audits, quality improvement initiatives and service development projects aimed at improving discharge processes, reducing delays and enhancing patient outcomes.
• Contribute to the collection, analysis and reporting of discharge performance data and key performance indicators.

Information Governance and Documentation

• Maintain accurate, timely and comprehensive patient records using electronic patient record systems and discharge planning tools.
• Ensure all assessments, referrals, discharge plans and communications are documented in accordance with professional, legal and organisational standards.
• Produce high-quality reports, assessments and transfer of care documentation to support safe and effective transitions between services.
• Maintain confidentiality and comply with all Information Governance, Data Protection and Caldicott requirements.

Professional Responsibilities

• Practice in accordance with the NMC Code and Trust policies and procedures.
• Maintain professional registration and undertake continuing professional development to ensure knowledge and skills remain current.
• Work autonomously whilst recognising limitations and seeking support when appropriate.
• Manage competing priorities effectively within a fast-paced acute hospital environment.
• Uphold the Trust's values and behaviours and contribute positively to team working and service delivery.

The Complex Discharge Nurse plays a pivotal role in facilitating safe, timely and person-centred discharges for patients with complex needs. Using a case management approach, the post holder will work across organisational boundaries to coordinate assessments, referrals and services, ensuring patients receive the right care, in the right place, at the right time. The role is fundamental to reducing delays, improving patient flow, enhancing patient experience and supporting the delivery of high-quality integrated discharge services.