Detailed job description and main responsibilities

Work independently managing own allocated case load.

To respond to referrals within 1 working day, notifying Discharge Team Manager/ Leader immediately should this not be achievable.

To work towards the specified Estimated Discharge Date (EDD) identified by the Clinical/ Multidisciplinary Team.

Review daily, each complex patient’s progress towards discharge to determine if the plan needs to be revised and actioned in order to achieve a timely and safe discharge.

To prepare complex patients and their relatives at the earliest opportunity in relation to planning for discharge – ensuring the philosophy of assessments taking place closer to home is reiterated rather than in the hospital setting.

To support ward staff and assist in coordinating patient discharge for those entering ‘end of life, liaising with necessary partners and organisations such as Continuing Health Care, local hospices, District Nurses, Voluntary sector and Charitable organisations.

Ensure the ‘discharge database’ is accurately completed and up-dated to enable Delayed Transfers of Care patients and the reason why they are delayed to be identified and counted on a daily basis.

To identify appropriate patients through the ‘trusted assessment’ process to the various ‘Discharge to Assess’ initiatives to bring care closer to home for patients.

To undertake Mental Capacity assessments in accordance with the Mental Capacity Act (2005) in relation to specific decisions pertinent to the patients discharge plan.

To lead and coordinate the NHS Continuing Health Care process in accordance with ‘The National Framework for CHC’ and based on the ‘trusted assessment’ agreed with SWCCG.

To inform and provide the Team Manager/ Leader with all data required to prepare the weekly SITREP report on Delayed Discharges in accordance with the Care Act (2014).

To escalate to the Team Manager/ Leader patients declining to leave an acute or community bed will require choice directive.

To undertake or deputise for some aspects of the Team Leaders role when necessary, such as attending meetings.

To cover and rotate through all areas as allocated by the Team Manager/ Leader – including Acute, Community sectors and the D2A care homes.

To participate in the delivery of new Trust initiatives related to the process of patient discharge.

Liaise closely with all the Infection Control and Risk Management Teams to minimise any risk to patients in the transfer / discharge process.

Respond to all verbal and written complaints in line with the Trust complaints procedure initiating resolutions where possible and report outcome to Discharge Team Manager/ Leader.

Ensure adherence to all measures stipulated in the Trust’s in patient Discharge Procedure and other policies related to the discharge process.

Knowledge, Skills and Experience Required

To have a full understanding of the Discharge Process and the knowledge and skills to apply effectively in practice to ensure a safe and timely patient discharge takes place.

To assist in identifying, negotiating and co-ordinating the movement of patients who are suitable to transfer to other health or social care facilities.

To promote integrated and collaborative working with health, social care teams and third sector providers.

To initiate and lead patient case conferences or ‘best interest’ meetings, as necessary with discussions and actions documented.

The post holder will be required to use a computer, either stands alone or as part of a networked system and will be responsible for the quality of information recorded.

To sensitively challenge conventional thinking that hinders or creates a delay in the process of patient discharge.

Measurable Results Areas

The post holder will maintain accurate records both written and electronic, deal with highly sensitive information respecting confidentiality and security at all times in accordance with Trust policies and data protection.

To support and actively participate in audits pertaining to patient discharge and whole system flow.

To contribute to the development of standards, protocols, care pathways and clinical audit when requested.

To contribute to strategies and use relevant information systems to collect and interpret data that will lead to the formulation of action plans that seek to improve the discharge process.

Communications and Working Relationships

To utilise information systems, internet, hospital intranet and results reporting to facilitate the discharge process.

To ensure the ‘discharge database’ is accurately up-dated, to capture all complex patients.

To attend designated multidisciplinary meetings to agree, set goals and action accordingly within a specified time scale.

To communicate with staff, patients, carers and relatives using a professional and sensitive manner to respond to a range of enquiries maintaining confidentiality at all times.

To involve the patient, relatives and carers offering information, literature, advice and guidance; keeping them fully informed of the discharge process and plan.

Ensure external communication links with all relevant stakeholders is established and maintained, by accurate information sharing with all social care & health community teams, General Practitioners and third sector organisations, such as Age UK.

Education and Training

To support the Discharge Team Manager/ Leader in assisting newly appointed team members to achieve understanding and competence in the art of Complex Discharge planning.

To provide support, education and training to nursing staff, including the induction of new staff and other multidisciplinary workers in all aspects of discharge planning.

Promote an environment through education and training that supports and encourages all staff to take ownership and proactively manage the process of patient discharge.

To develop own and others knowledge, skills and practice within the field of discharge planning.

To keep up to date with National Legislation, Best Practice and guidance relating to patient discharge.

To participate in relevant nursing forums to establish links, enable open discussion, allowing the sharing of knowledge, skills and information regarding the subject of discharge planning.

On a rotational basis – deliver/ participate in the Trusts mandatory adult safeguarding training. To act as a role model and source of local knowledge to ward staff pertaining to discharge planning in relation to services and resources available.