Job responsibilities
Based
in UHP (Derriford Hospital), the post holder will be accountable to the IHDT
Deputy Team Manager on a day to day basis for the leadership and management of
the discharge case managers; the post holders relationship with the team
manager will be collaborative and seamless. The team consists of Nurse
Assessors, Social Workers, CCWs, Health and Social Care Assessors and a team of
Discharge Case Managers. The social work offer is a combination of both
Plymouth City and Devon County Council (DCC) given the geographic footprint
covered.
The
post holder will have knowledge and understanding of acute and community
discharge pathways including, but not limited to; Homefirst, Discharge to Assess,
End of Life, Community Hospitals and Specialist Pathways such as neurological
or stroke care. Knowledge of the wider
market place such as care homes, domiciliary care and support services,
underpinned by an understanding of commissioning, will be invaluable, and you
will need to be able to demonstrate understanding of legislative and policy
frameworks such as CHC and the Care Act.
Daily
deliverables include supporting with escalation calls
where patient flow issues are communicated and resolved, and providing an
overview and assurance to the western system
of IHDT data and delayed transfers of care.
Ward MDTs also required to be supported on a daily basis by the
IHDT, and it is a function of the IHDT management team to coordinate this
efficiently.
Due
to the complexity of some people requiring discharge, there will be a need to
provide advice
to staff regarding safeguarding, and to assist in Mental Capacity assessments
and Best Interest decisions, including chairing meetings where required. This is also an opportunity to develop and
embed strength-based practice within a broad and well established team
environment.
The Integrated Hospital Discharge Team work on a flexible rota
shift system. The service covers seven days and the Discharge Nurse will be
part of a 7 day roster. An important part of the role is liaison with ward staff,
patients and their families and carers, to ensure safe, timely discharge from
hospital. The post holder will also be able to provide a professional and
trusted interface between hospital, primary care, community and social care
settings.
PRIMARY DUTIES & AREAS OF RESPONSIBILITIES
Clinical
1.
To
be professionally responsible and accountable for all aspects of your own work
including caseload management.
2.
To
act as a Care Coordinator for patients/Carers and arrange for appropriate care
packages to be set up
3.
To
be responsible for assessing, diagnosing, implementing, planning and reviewing
complex needs and packages of care in partnership with patients, carers and
multi-professional agencies including case conferences.
4.
Through
liaison with other registered practitioners, and without face to face patient
assessment, care needs may be agreed and implemented.
5.
To
use clinical reasoning and utilise a wide range of appropriate treatment
options to formulate individualised programmes of care and to provide
intervention plans for people with a wide range of complex conditions.
6.
Have
good communication skills as to effectively communicate with patients and their
carers, including sensitive and accurate information about their condition.
7.
The
post holder will have to provide and receive complex, sensitive and
confidential information and overcome potential barriers to communication, such
as language, disability as well as dealing with concordance and barriers from
patients to the prescribed treatment.
8.
To
provide good quality advice and information regarding the range of realistic
options available for meeting the persons care needs and to arrange for care
to be set up effectively with supporting documentation.
9.
Maintain
effective working relationships with multidisciplinary team and deliver a cost
effective quality service to patient/carers within a defined geographical area.
10. Involvement in
initiation and participation of reviewing existing clinical policies and
procedures in steering groups and committees.
11. To co-ordinate and
manage a caseload (or caseloads) and delegation of tasks within the skill mix
of the Team.
12. To be accountable for
the delivery of service by facilitating holistic evidenced based practice to
patients, in accordance with National and organisation approved
policies/procedures and individual care plans.
13.
The
aim of which is ensuring maximum independence and quality of life in a
constantly changing environment.
14.
To
take a Lead role within the team when dealing with complex/urgent situations
which can be emotionally challenging e.g. terminal illness
15.
To
supervise, monitor, develop standards and audit of care delivered to patients
and Carers by the multi-disciplinary team.
16.
To
undertake, develop and maintain nursing skills and competencies which are
required for their role.
17.
To
enhance the skill mix of the multi-disciplinary team and ensure that the
ever-changing health needs of patients are met.
18.
To
act as advisor/professional leader in health care issues and clinical practice
which are often complex and urgent.
19.
Support
links across & liaison with patients, carers and the wider health, social
care and voluntary community.
20.
To
triage and accept appropriate referrals directly from other disciplines, or
refer to other agencies where appropriate.
21.
To
Case Manage/Care Co-ordinate packages of care and to work within the framework
of the Care Co-ordination Team by providing holistic care and demonstrate
positive leadership skills.
Professional
1.
To
undertake appraisals for Discharge Case Managers who are line managed by this
post holder.
2.
To
facilitate and develop Discharge Case Managers.
3.
To
participate in Reflective Practice, Clinical Supervision and Appraisals for
Discharge Case Managers as per organisation policies.
4.
Identify
areas of practice/role development and enable and support staff to initiate
change.
5.
To
Manage and prioritise a defined caseload and delegate where appropriate.
6.
To
participate in policy development through professional forums and implement
practice ensuring the clinical practice reflects national and local drivers.
7.
To
be responsible for recruitment and selection of new staff, including chairing
appointments panels.
Organisational
1.
To
be responsible for a designated area of work, as agreed with the Team Leader,
and to plan and organise efficiently and effectively with regard to caseload
management and use of time.
2.
To
decide priorities for own work area, balancing other patient related and
professional demands, and ensure that these remain in accordance with those of
the Care Coordination as a whole.
3.
To
maintain accurate, comprehensive and up-to-date electronic documentation, in
line with NMC Standards of Practice and local/Organisational policy.
Communicate assessment and treatment results to the appropriate disciplines in
the form of reports and letters as appropriate.
4.
To
be actively involved in the collection and entry of appropriate data and
statistics in line with Care Coordination Organisational policies and
procedures.
5.
To
be aware of Health and Safety aspects of your work and implement any policies,
which may be required to improve the safety of your work area, including your
prompt recording and reporting of incidents to senior staff, and ensuring that
equipment use is safe.
6.
To
comply with the organisational and departmental policies and procedures and to
be involved in the reviewing, instigating, devising and updating as
appropriate.
7.
To
undertake any other duties that might be considered appropriate and within the
individuals competence, by the Deputy Team Leader or the Team Leader.
