Additionally, the Specialist Discharge Coordinator will participate in the Pathway 1 Discharge Pathway initiative, assist in referrals for bridging care packages, and maintain accurate clinical system documentation. The position requires active engagement in multidisciplinary team meetings and an emphasis on promoting best practices for discharge, aiming to reduce hospital length-of-stay and prevent readmissions. Continuous training and feedback collection from patients and caregivers will also be integral to the role, as well as ensuring adherence to legal frameworks related to capacity and discharge processes.
As a Discharge Case Manager, you will be aligned to specific hospital inpatient areas and will be responsible for a case load of patients at all levels of complexity to progress their hospital journey from admission to discharge.
You will play a vital role within hospital flow and be the escalation point to progress the patients' hospital journey and in turn facilitate a timely discharge with the aim to meet every patient's Estimated Dates for Discharge (EDD) with the overall objective to reduce the hospital length of stay
Ensure that patients, relatives and carers are provided with information about discharge planning and have that information explained, so that they can be supported in their decision making to help promote and enable independence in a timely manner
To participate in a new Pathway 1 Discharge Pathway across local boroughs; working closely with the hospital social work team and community teams to refer appropriate patients for bridging packages of care. This role includes completing these referrals and co-ordinating the discharge of non-complex pathway 1 patients, ensuring they are discharged home in a timely manner.
In liaison with ward staff, community, social services and other healthcare colleagues facilitate timely, appropriate and safe discharge of patients.
Act as a trusted assessor for care homes and community bed settings by completing the initial discharge conversations and all relevant discharge paperwork.
Complete initial discharge conversations with patient and their families to determine home situation and any concerns
Ensure Early Discharge Notification (EDN) to be completed within 24 hours of hospital admission,
Needs Based Assessment (NBA) and any other onward referrals are completed in a timely manner
Assist ward staff to complete Fast track paperwork Accordingly
become P1 pilot coordinator to complete phone referrals to the appropriate Home 1st teams
Work as part of the hospital-based discharge team to ensure standards relating to discharge practice
About us
Responsibilities
In liaison with ward staff, community, social services and other healthcare colleagues facilitate timely, appropriate and safe discharge of patients.
Act as a trusted assessor for care homes and community bed settings by completing the initial discharge conversations and all relevant discharge paperwork. Ensure that the Early Discharge Notification (EDN) to be completed within 24 hours of hospital admission, Needs Based Assessment (NBA) and any other onward referrals are completed in a timely manner
Work as part of the hospital-based discharge team to ensure standards relating to discharge practice are evidence based (in accordance with the HCPC/NMC Code of Professional Conduct, and The Trusts Discharge Policy. Proactively support the coordination of patients on pathway 1.
Ensure all Clinical systems are kept up to date, these include Cerner, Discharge Dashboards and Optica throughout the day
Actively promote awareness of safe discharge processes for patients and their carers to prevent re-admission to hospital.
Actively support and facilitate the transfer of patients who are privately funding their care to prevent extended length of stay. To adhere to the National and Trust Policy for Discharge to family and carers within the agreed time frame to avoid extended length of stay.
To provide support and advice to pre-assessment clinics in the identification of potential discharge problems and generate solutions; thereby facilitating early discharge and potential need for multi- disciplinary involvemen.
Attend Daily Reason to Reside Meetings, MDT meetings, Professional and family meetings, Daily Board rounds on allocated wards. Promote the use of estimated date of discharge and reinforce within the multi-disciplinary teams; the need to ensure that all patients and carers are advised
Ensure the person and any carers, family or friends are involved in and informed about all aspects of the discharge process
Promote nurse led discharges at weekends and assist on competency levels to empower staff both at ward level and within the discharge team
To have a good knowledge and understanding of mental capacity and deprivation of liberty legislation and other legal frameworks.
In the event of a major incident, support the immediate transfer and discharge of patients to facilitate capacity
Training For Ward Staff on Discharge Process
Seek feedback from patients and carers.
Develop and maintain own competence in agreed basic and advanced clinical skills relating to discharge processes
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