Detailed job description and main responsibilities

• Work with the hospital teams to proactively identify patients who need advice or support at home/care setting to enable a safe discharge from hospital.
• Act as an information source regarding available internal and external resources and develop links and/or improve service internally.
• Support and professionally challenge colleagues to ensure correct and safe discharge pathway for patients is identified and followed.
• Support, guide and monitor the multidisciplinary team to ensure correct assessments have taken place in a timely manner and effective referrals provided.
• Participate as a member of the multidisciplinary team when difficulties are identified in the assessment and care planning process.
• Identify and monitor bottlenecks within the system and develop processes to resolve.
• Routinely collect and maintain data about referred patients and any internal or external reasons for delays.
• Ensure, with other members of the MDT, that patients and their careers are involved and informed of discharge arrangements and that discharge planning is documented on EPIC.
• Work closely with all staff to ensure best practice is in place to reduce the number delays in discharge and promote a positive experience for the patient.
• Identify significant trends or patterns, which detract from the performance of the trust.
• Champion good practice and implement strategies to reduce delays in discharge.
• Establish plans of care for patients with complex needs in collaboration with the health care team that will ensure continuity of care and efficient use of resources.
• Support and facilitate the implementation of local and national guidelines and recommendations which are related to this service.
• Lead in the co-ordination of professional's meetings where there are complex discharge planning requirements, ensuring involvement of all relevant disciplines/agencies.
• Ensure carers are involved in discharge planning and that carers can ask for an assessment of any services that they need to support the discharge of the person that they care for.
• Actively participate in the development of a whole systems approach, which promotes continuous improvement in the quality of patient care and the efficiency of the patient pathway.
• Act as a resource across the trust for all staff groups on all complex and sensitive discharge issue.

This job description is an indication of the type and range of tasks that are expected of the postholder, and other duties may be required, in line with the role and the banding.  It will be reviewed and amended from time to time in consultation with the postholder to take account of changing organisational need.