Integrated Hospital Discharge Nurse

Job responsibilities

Please refer to the job description for full details of the role, the following is a summary of the Job Description sections:

Responsibility for People Management.

As a Care Coordinator, you will arrange appropriate care packages for patients and carers, assess, diagnose, implement, plan, and review complex needs in partnership with multi-professional agencies, and use clinical reasoning to formulate individualized care programs. You will provide advice on care options, plan and deliver care from hospital to community, manage and prioritize caseloads, and delegate tasks. Acting as a role model, you will maintain a learning environment, support educational development, and teach clinical skills. You will participate in clinical supervision, support recruitment, mentor new staff, coordinate leave and rotas, and manage team operations in the absence of the service manager. Effective communication with the clinical team and stakeholders is essential, as is personal and professional development. You will also be involved in policy development, recruitment, time and staff management, and ensuring documentation is completed timely. Flexibility in your working week and support for colleagues are crucial to meet patient and service needs.

Responsibility for financial and/or physical resources

You will ensure cost-effective and quality-controlled use of products, act as an authorized signatory for supplies and expenses, and manage staff-related financial matters such as overtime and annual leave. You will oversee and authorize equipment usage, maintain effective multidisciplinary team relationships, and deliver cost-effective, high-quality services to patients and carers. Additionally, you will contribute to resource governance through informed prescribing decisions and exercise a duty of care in using the organisations equipment and resources efficiently.

Responsibility for administration

The post holder will be required to use various devices such as computers, mobile phones, and lone working devices, adhering to Livewell Southwest policies. Compliance will be monitored through observation, spot checks, and incident management. They will oversee the standard of patients' records through audits or peer reviews and maintain regular discussions with team members. Additionally, they will support the team manager in recording accurate clinical activity data, maintain lone working information for identified staff, and monitor adherence to the lone working policy and device usage.

Responsibility for people who use our services

The post holder is accountable for delivering holistic, evidence-based practice to patients and carers, ensuring maximum independence and quality of life in a dynamic environment. They achieve positive outcomes through collaboration with multi-professional agencies, utilizing specialised clinical skills and exercising high judgment in clinical care. Acting as a patient advocate, they provide tailored education, advice, and support, manage referrals, and prioritise patient needs. They conduct risk assessments, ensure privacy and dignity, promote independence, and comply with confidentiality laws. Additionally, they supervise care standards, participate in audits, and adhere to professional codes and policies, providing both planned and unplanned care within a defined area.

Responsibility for implementation of policy and/or service developments

Ensure adherence to Livewell Southwest Policies by developing, reviewing, and auditing guidelines and protocols in line with NICE guidance and best practices, and support their implementation. Promote best practice sharing within the region, participate in developing and monitoring standards, and identify community health needs for new projects, research, and audits. Provide leadership, support staff in initiating change, and act as a change agent. Facilitate service objectives development, support patient safety investigations, and monitor new evidence to improve patient care. Develop links with professional and voluntary bodies, lead practice innovation, and implement changes. Develop health promotion and disease management initiatives, identify research areas, and stay informed on legislation and prescribing developments, applying relevant policies.

Other Responsibilities

To maintain accurate patient records, which are confidential, up to date, legible and that all care given has been documented. These records must be maintained as specified in the LWSW Policies, NMC guidelines and Government directives. To be responsible for organising own time management on a daily basis in line with caseload demands balancing patient needs with the non-clinical aspect of the role. To participate in an annual appraisal of their work in line with the Knowledge and Skills Framework (KSF) where the job description will be reviewed, and objectives set. In line with the annual development plan the post holder will be expected to undertake any training or development required to fulfil their role. To remain updated and competent and ensure that clinical practice is evidence based. Assume responsibility for own professional development and personal knowledge.

COMMUNICATIONS AND RELATIONSHIPS

Links across & liaises with; primary care, secondary care, mental health, voluntary & statutory organisations, SWAST, 111, Users & Carers, Members of the public, Integrated Localities, Specialist Services and Urgent and Intermediate Care (and all stakeholders as required). Will be expected to liaise, develop, and maintain effective communication at local, regional and national level with patients, relatives and carers, members of the public, Consultants, GPs and any other medical nursing or therapy staff. Community and Acute providers, Intermediate Care service staff, Livewell Southwest, Social Services, other specialist practitioner, statutory and voluntary organisations. To maintain and foster good relationships with professionals and non-professional colleagues concerned with the provision or development of healthcare services. To lead and participate in team activities to develop and consolidate a cohesive and supportive team ensuring openness within the team. Have excellent communication skills as to effectively communicate with patients and their carers, including sensitive and accurate information about their condition, showing empathy and sensitivity. Establish the dynamic process of understanding, reflecting, active listening and checking understanding, thus developing a therapeutic relationship with patients and carers. 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. Maintain accurate and up to date patient records and inform other professionals about changes in patients condition. Ensure effective and timely information exchange is maintained, verbally, written or electronically. Use a high level of communication/negotiation skills daily with other health and social care professionals. To inform each, as appropriate, of the highly complex and sensitive information related to the patients condition required to achieve the best outcomes and care pathways. Demonstrate highly developed communication skills required to take a lead role in case discussions/case conferences concerning service users in their caseload. To lead and participate in team activities so as to develop and consolidate a cohesive and supportive team ensuring openness within the team. Able to communicate the role and eligibility criteria of the IHDT

Knowledge

Essential

• Up to date knowledge of current practice within the area specified in job purpose
• Knowledge of national and local frameworks and strategies
• Ability to translate best practice evidence and national policies in practice.
• Background and development knowledge of Government Policies and changes in Primary Care.
• Understanding of NICE guidance
• The post holder will have experience undertaking Incident Investigations.
• Ability to undertake holistic patient centred assessment

Desirable

• Evidence of continued recent academic and clinical development
• Knowledge of service development
• Previous primary care / community experience.
• Competent to the level for post in each of the dimensions of the knowledge and skills framework.
• Knowledge and experience In complex discharge planning.
• Demonstrate knowledge and understanding of the continuing health care framework and eligibility.

Additional requirements

Essential

• Familiar and committed to the principles and values of the NHS.
• Demonstrate commitment to focus on quality, promotes high standards to consistently improve patient outcomes.
• Creates and fosters a culture of openness, honesty, integrity and inclusiveness.
• Ability to work flexibly, demonstrating commitment to partnership working.
• Ability to access / travel to other community hospital sites across the locality.

Desirable

• Values diversity and difference.
• Knowledge of Salus, Seehr, Eclipse , system1

Specific skills

Essential

• Good time management
• Autonomous practitioner with the ability to work unsupervised.
• Ability to assess and treat patients using evidence based practice.
• Ability to work alongside clinicians to support and enhance quality of patient care.
• Excellent interpersonal skills in Leadership, co ordination and management skills.
• Delegation skills.
• IT Literate.
• Highly motivated with ability to influence and inspire others.
• Ability to act as a champion for patients and carers and their interests, ensuring the patients voice has an impact on service developments.

Desirable

• Flexible/Adaptable /Team player
• Evidence of using initiative to put innovation into practice

Qualifications

Essential

• 1st level nurse registration (degree or diploma)
• Current Registered Nurse with relevant, registered experience
• Experience of mentoring.
• Specific post basic qualification / or equivalent experience relevant with Discharge Planning
• NMC registration

Desirable

• Recognised teaching qualification mentorship or equivalent.
• Leadership experience/qualifications
• Nursing prescribing qualification or willingness to undertake.

Experience

Essential

• Relevant post registered experience
• Able to demonstrate Clinical Management skills appropriate to the role.
• Proven relevant experience of Leadership.
• Experience in leading and development of new pathways of care and delivering best practice
• Experience in managing sensitive issues and overcoming obstacles in communication.

Desirable

• Experience and working knowledge of community setting desirable.
• Management/Leadership qualification
• Experience of influencing change in the workplace

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).