To manage a caseload of patients for designated ward / delegated area of responsibility. Ensure discharges are lined up for the earliest opportunity each day, escalating where discharges are at risk of failing. Keep up to date records of the patients discharge planning and journey in the patient notes and on the complex discharge database SW TOCH and SW IP Community Waiting lists. Work with the MDT to ensure all patients have up to date, realistic discharge plans and take action to implement, monitor and amend the plans, if necessary, in partnership with all relevant colleagues. Attend daily board rounds on allocated wards to act as "discharge key worker" ensuring the following actions are achieved on a daily basis:
To support and coordinate the discharge tasks for designated wards / delegated area of responsibility in a safe, timely and pro-active manner, working in partnership with the multidisciplinary team (MDT), including nursing, medical, therapy, various social service partners, carers, care agencies, community teams, clinical commissioning groups, TOCH, D/C leads at acute hospitals, voluntary agencies, next of kin and other external partners.
Ensure plans for transferring patients to community services are progressed with the patient, next of kin and MDT to facilitate discharge from hospital once deemed medically stable.
Act proactively to provide a reduction in length of stay and delayed discharges.
Support the teams on all aspects of discharge planning and escalate any issues with complex discharge.
Liaise with care agencies and care homes to establish dates for assessments and agree transfer dates; work alongside social services, ICB and trusted assessors to ensure return to placement and restarts of care packages are completed following policy.
Escalate any delay within the discharge planning process to appropriate team leaders, clinical leaders, and service managers. This may include MDT assessments, diagnostics, family, care home delays etc.
Liaise with the bed managers to ensure they are aware of all medically fit patients or when discharges are at risk.
Participate in clinical care when required, including personal care, patient handling, observations, assessments, and phlebotomy.
Further information about the Trust and this role can be found on the Job Description and Person Specification document attached.
We are happy to talk Flexible Working - all requests for flexible working options can be discussed as part of the interview process.