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Facilitate discharge from the acute hospitals to the patients own home completing an assessment of ongoing needs and following the key home first principles:
We should not define peoples long term needs within a hospital setting.
If the patient is admitted from their own home then they should be discharged directly back to their own home wherever possible it must always be the aim and initial focus/consideration
There should be no delay in getting people home or to the next step immediately, since it can be detrimental to their long term health outcomes.
Assessments are more contextualised outside a hospital environment especially within the persons own home or when they have had the chance to recover.
If after -care services are required, a rehabilitation or recovery approach must always be considered first.
Ongoing care and trusted handover should underpin all steps.
Act as a key point of contact for acute clinicians including consultants, other members of the team and community based clinicians/services.
Work within and across professional and organisational boundaries, liaising with consultants, ward managers, other professionals and statutory and voluntary agencies to deliver individualised and expert assessment and discharge guidance to a high standard, and leading communication with all stakeholders.
Champion a Home first approach for all discharges only requesting placements where there is no alternative to manage the risks.
Support colleagues in delivering high quality care that delivers best value and meets the requirements of the national and local hospital discharge policy.
Be an autonomous practitioner, responsible for provision of triage to facilitate discharge planning, assessment and case management of clients referred to the service.
Facilitate transfer of relevant, up to date information, assessments and care plans to the appropriate service in a timely manner, including the inclusion of test results such as covid-19 in line with agreed requirements.
Ensure that the patient's individual needs, cultural beliefs, dignity and privacy are maintained at all times.
Work in collaboration with the system partners and other providers on the further development of discharge and inter-face services to be responsive to patient needs.
Work at an advanced level drawing on a diverse range of knowledge in complex decision making to determine evidence-based therapeutic interventions
Identify patients whose discharge is delayed and inform System Partners of the most urgent in priority order, to positively influence funding decisions, and by use of specialist nursing knowledge, challenging inappropriate decisions.
If delays occur, identify causative factors and seek solutions to them in partnership with clinical teams.
Chair daily Medically Optimised for Discharge huddle
Maintain and update the Trusts Discharges Intranet Site
Implement and uphold the Oxfordshire Protocol of Choice
Maintain a list of those who no longer meet the criteria to reside, detailing their discharge plans
Take the lead in the collection and presentation of the details of the inpatients who no longer meet the criteria to reside
Take a lead in ensuring patients who meet the eligibility criteria for continuing health care are identified and assessed appropriately.
Convene and chair multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
Be responsible for the receipt, organisation, prioritisation, triage and decision making, assessment and onward referral of patients with ongoing rehabilitation and social care needs through effective discharge planning.
Have access to, and use, the relevant computer systems to enable the decision making triage to take place within a setting away from the ward environment.
Ensure patients receive enhanced discharge planning, continuity of care and the seamless transition between care providers beyond the acute hospital environment- including returning home, placement within a care home facility, or transfer to another inpatient facility for further rehabilitation or complex discharge planning.
Liaise with the Single Point of Access, Community Hospitals and Liaison Hub team to ensure that available beds are used as effectively as possible and occupancy is maintained at 100% wherever possible
Be professional, legally responsible and accountable for all aspects of work undertaken, including the assessment and signposting of the patients to ensure a high standard of clinical expertise is delivered, maintaining up to date and accurate records as an autonomous practitioner.
Shared responsibility for the continuing professional development and overall performance of other team members, students and assistants.
Participate in providing a 7 day service, covering extended weekdays and weekends on a rota basis.
Play a key role in the provision of a high quality service. Supported by clinically specialised staff, the post-holder will build on previous experience to enable further development of clinical and managerial competencies.
Work within and adhere to the Nursing and Midwifery Council (NMC) standards of practice and the Trust relevant policies and guidelines and also National guidelines.
Undertake evidence-based audit and research projects to further own and the teams clinical practice. Make recommendations to the manager of service for changes to practice by the team. May lead the implementation of specific changes to practice or contribute to service protocols.
Provide education and support to ward staff in clinical settings on current legislation, discharge planning, and NICE guidance.
Lead and advise in the training and education of all staff in all aspects of Discharge Planning and further relevant developments either in a group setting or on an individual basis
Design, develop and deliver appropriate training packages.
Effectively manage human, financial, material and information resources
Actively manage the Team budget and apply detailed level of understanding of the budgetary constraints
Person specification- Lead Discharge Liaison Nurse
Requirements
Essential
Desirable
Qualifications & Training
Nursing Degree
Specialist training or experience in discharge management
Registered Nurse with specialist training or experience of discharge management in an acute hospital setting
Evidence of post qualifying education
Experience
Experience of working in Nurse led discharge
Previous experience with discharge planning
Previous involvement in preparing reports for discharge delays
Experience of working in Nurse led discharge
Experience of resolving complex discharges across more than one area where trust wide issues arise
Experience with End of Life care management
Experience of operational management
Knowledge & Skills
Excellent written and verbal communication skills with the ability to converse in a positive manner with all levels of professional colleagues, carers and patients
Negotiation and facilitation skills
Demonstrate excellent personal communication.
Establish and maintain effective two-way communication channels with individuals and groups
Excellent Knowledge of Health and Social Care services, current issues and trends relating to discharge.
Registered Nurse with specialist training or experience of discharge management in an acute hospital setting
Aware of current developments in discharge agenda
Previous involvement in preparing reports relating to discharge delays.
Previous experience with discharge planning
Excellent Knowledge of Health and Social Care services, current issues and trends relating to discharge.
Knowledge of NHS Continuing Care eligibility criteria
Excellent understanding of the importance of discharge planning, the discharge process and potential obstacles.
Assesses and analyses specialist information relating to the management of patient discharge
Computer literate with good computing skills and ability to use programmes such as Word and Excel competently.
Good presentation skills
Resourceful, ability to work on own initiative and apply sound judgement.
Ability to work efficiently on a multidisciplinary basis both internally and externally to the organisation.
Ability to demonstrate a patient orientated approach to work.
Display sound analytical and critical thinking ability in complex and rapidly changing situations and develop a range of options
Have a working knowledge of Continuing Health Care legislation.
Problem solving skills and the ability to respond to sudden unexpected demands
Evidence of leadership skills
Personal Attributes
Ability to remain calm under pressure, and in stressful situations
Strategic influencing
Intellectual flexibility
Drives for results
Can hold to account
Motivated individual, commitment to personal & professional development
Able to consistently adopt behaviours that demonstrate a commitment to and understanding of the Trust values towards everyone who uses or delivers our patient services.
Adaptability, flexibility and ability to cope with uncertainty and change
Job Summary:
Operating within the framework of the Hospital Discharge and Community Support Guidance (March 2022), the post holder will work in partnership with colleagues in the acute sector, social services, continuing care, community services and Voluntary Community Sector to ensure that patients identified are assessed and transferred safely to appropriate community based services in a timely and seamless manner.
Responsible for ensuring smooth daily operations as a case manager and to act as a key point of contact and subject matter expert to be agreed with the post holder to support with complex discharge queries.
Facilitate discharge from the acute hospitals to the patient's own home completing an assessment of ongoing needs and following the key home first principles:
o We should not define people's long term needs within a hospital setting.
o If the patient is admitted from their own home then they should be discharged directly back to their own home wherever possible- it must always be the aim and initial focus/consideration
o There should be no delay in getting people home or to the next step immediately, since it can be detrimental to their long term health outcomes.
o Assessments are more contextualised outside a hospital environment especially within the person's own home or when they have had the chance to recover.
o If after -care services are required, a rehabilitation or recovery approach must always be considered first.
o Ongoing care and trusted handover should underpin all steps.
Act as a key point of contact for acute clinicians including consultants, other members of the team and community based clinicians/services.
Facilitate discharge from the acute hospitals to the patients own home completing an assessment of ongoing needs and following the key home first principles:
We should not define peoples long term needs within a hospital setting.
If the patient is admitted from their own home then they should be discharged directly back to their own home wherever possible it must always be the aim and initial focus/consideration
There should be no delay in getting people home or to the next step immediately, since it can be detrimental to their long term health outcomes.
Assessments are more contextualised outside a hospital environment especially within the persons own home or when they have had the chance to recover.
If after -care services are required, a rehabilitation or recovery approach must always be considered first.
Ongoing care and trusted handover should underpin all steps.
Act as a key point of contact for acute clinicians including consultants, other members of the team and community based clinicians/services.
Work within and across professional and organisational boundaries, liaising with consultants, ward managers, other professionals and statutory and voluntary agencies to deliver individualised and expert assessment and discharge guidance to a high standard, and leading communication with all stakeholders.
Champion a Home first approach for all discharges only requesting placements where there is no alternative to manage the risks.
Support colleagues in delivering high quality care that delivers best value and meets the requirements of the national and local hospital discharge policy.
Be an autonomous practitioner, responsible for provision of triage to facilitate discharge planning, assessment and case management of clients referred to the service.
Facilitate transfer of relevant, up to date information, assessments and care plans to the appropriate service in a timely manner, including the inclusion of test results such as covid-19 in line with agreed requirements.
Ensure that the patient's individual needs, cultural beliefs, dignity and privacy are maintained at all times.
Work in collaboration with the system partners and other providers on the further development of discharge and inter-face services to be responsive to patient needs.
Work at an advanced level drawing on a diverse range of knowledge in complex decision making to determine evidence-based therapeutic interventions
Identify patients whose discharge is delayed and inform System Partners of the most urgent in priority order, to positively influence funding decisions, and by use of specialist nursing knowledge, challenging inappropriate decisions.
If delays occur, identify causative factors and seek solutions to them in partnership with clinical teams.
Chair daily Medically Optimised for Discharge huddle
Maintain and update the Trusts Discharges Intranet Site
Implement and uphold the Oxfordshire Protocol of Choice
Maintain a list of those who no longer meet the criteria to reside, detailing their discharge plans
Take the lead in the collection and presentation of the details of the inpatients who no longer meet the criteria to reside
Take a lead in ensuring patients who meet the eligibility criteria for continuing health care are identified and assessed appropriately.
Convene and chair multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
Be responsible for the receipt, organisation, prioritisation, triage and decision making, assessment and onward referral of patients with ongoing rehabilitation and social care needs through effective discharge planning.
Have access to, and use, the relevant computer systems to enable the decision making triage to take place within a setting away from the ward environment.
Ensure patients receive enhanced discharge planning, continuity of care and the seamless transition between care providers beyond the acute hospital environment- including returning home, placement within a care home facility, or transfer to another inpatient facility for further rehabilitation or complex discharge planning.
Liaise with the Single Point of Access, Community Hospitals and Liaison Hub team to ensure that available beds are used as effectively as possible and occupancy is maintained at 100% wherever possible
Be professional, legally responsible and accountable for all aspects of work undertaken, including the assessment and signposting of the patients to ensure a high standard of clinical expertise is delivered, maintaining up to date and accurate records as an autonomous practitioner.
Shared responsibility for the continuing professional development and overall performance of other team members, students and assistants.
Participate in providing a 7 day service, covering extended weekdays and weekends on a rota basis.
Play a key role in the provision of a high quality service. Supported by clinically specialised staff, the post-holder will build on previous experience to enable further development of clinical and managerial competencies.
Work within and adhere to the Nursing and Midwifery Council (NMC) standards of practice and the Trust relevant policies and guidelines and also National guidelines.
Undertake evidence-based audit and research projects to further own and the teams clinical practice. Make recommendations to the manager of service for changes to practice by the team. May lead the implementation of specific changes to practice or contribute to service protocols.
Provide education and support to ward staff in clinical settings on current legislation, discharge planning, and NICE guidance.
Lead and advise in the training and education of all staff in all aspects of Discharge Planning and further relevant developments either in a group setting or on an individual basis
Design, develop and deliver appropriate training packages.
Effectively manage human, financial, material and information resources
Actively manage the Team budget and apply detailed level of understanding of the budgetary constraints
Person specification- Lead Discharge Liaison Nurse
Requirements
Essential
Desirable
Qualifications & Training
Nursing Degree
Specialist training or experience in discharge management
Registered Nurse with specialist training or experience of discharge management in an acute hospital setting
Evidence of post qualifying education
Experience
Experience of working in Nurse led discharge
Previous experience with discharge planning
Previous involvement in preparing reports for discharge delays
Experience of working in Nurse led discharge
Experience of resolving complex discharges across more than one area where trust wide issues arise
Experience with End of Life care management
Experience of operational management
Knowledge & Skills
Excellent written and verbal communication skills with the ability to converse in a positive manner with all levels of professional colleagues, carers and patients
Negotiation and facilitation skills
Demonstrate excellent personal communication.
Establish and maintain effective two-way communication channels with individuals and groups
Excellent Knowledge of Health and Social Care services, current issues and trends relating to discharge.
Registered Nurse with specialist training or experience of discharge management in an acute hospital setting
Aware of current developments in discharge agenda
Previous involvement in preparing reports relating to discharge delays.
Previous experience with discharge planning
Excellent Knowledge of Health and Social Care services, current issues and trends relating to discharge.
Knowledge of NHS Continuing Care eligibility criteria
Excellent understanding of the importance of discharge planning, the discharge process and potential obstacles.
Assesses and analyses specialist information relating to the management of patient discharge
Computer literate with good computing skills and ability to use programmes such as Word and Excel competently.
Good presentation skills
Resourceful, ability to work on own initiative and apply sound judgement.
Ability to work efficiently on a multidisciplinary basis both internally and externally to the organisation.
Ability to demonstrate a patient orientated approach to work.
Display sound analytical and critical thinking ability in complex and rapidly changing situations and develop a range of options
Have a working knowledge of Continuing Health Care legislation.
Problem solving skills and the ability to respond to sudden unexpected demands
Evidence of leadership skills
Personal Attributes
Ability to remain calm under pressure, and in stressful situations
Strategic influencing
Intellectual flexibility
Drives for results
Can hold to account
Motivated individual, commitment to personal & professional development
Able to consistently adopt behaviours that demonstrate a commitment to and understanding of the Trust values towards everyone who uses or delivers our patient services.
Adaptability, flexibility and ability to cope with uncertainty and change
Job Summary:
Operating within the framework of the Hospital Discharge and Community Support Guidance (March 2022), the post holder will work in partnership with colleagues in the acute sector, social services, continuing care, community services and Voluntary Community Sector to ensure that patients identified are assessed and transferred safely to appropriate community based services in a timely and seamless manner.
Responsible for ensuring smooth daily operations as a case manager and to act as a key point of contact and subject matter expert to be agreed with the post holder to support with complex discharge queries.
Facilitate discharge from the acute hospitals to the patient's own home completing an assessment of ongoing needs and following the key home first principles:
o We should not define people's long term needs within a hospital setting.
o If the patient is admitted from their own home then they should be discharged directly back to their own home wherever possible- it must always be the aim and initial focus/consideration
o There should be no delay in getting people home or to the next step immediately, since it can be detrimental to their long term health outcomes.
o Assessments are more contextualised outside a hospital environment especially within the person's own home or when they have had the chance to recover.
o If after -care services are required, a rehabilitation or recovery approach must always be considered first.
o Ongoing care and trusted handover should underpin all steps.
Act as a key point of contact for acute clinicians including consultants, other members of the team and community based clinicians/services.
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