Job summary
Discharging an individual on to the right care pathway when they no longer need to remain in a hospital or community bed requires a whole system approach. Every local health and care system has a Care Transfer Hub where (physically and virtually) relevant community services across sectors (e.g. health, social care, housing, voluntary sector) are linked together.
The hub coordinates care for people who require care and support after discharge from hospital, and any support for unpaid carers providing care. This covers any patient discharged from hospital or community beds regardless of the area they are resident in.
The hub is staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support if needed. Decisions about what long-term support package is needed should not be taken in hospital wards.
The hub provides a single point of contact for professionals and families/carers in relation to discharge planning and delivery.The hub operates 7 days a week, 364 days per year ensuring that discharges are timely.
The hub supports safe discharges through close working with the acute and community wards, quality assurance of information and practical support, including proactive early identification of those who may become ready for discharge, supporting planning as early as possible following admission.
Main duties of the job
To facilitate effective discharge practice by providing support and expert nursing advice to STH, SCC, patients and their carers. Supporting Nurses, Therapist, Admins and Discharge Navigators directly to plan for safe timely discharge.
To work closely with the other professional leads in the Hub to identify and mitigate risks to service delivery. To work effectively together in the interests of the patient.
Provide operational support and leadership to all Care Transfer Hub staff.
Provide clinical support and leadership to the Registered Nursing Care Transfer Hub Workforce.
To deputise for the Care Transfer Hub Manager (Physical).
To support the Care Transfer Hub, implement any operational changes to the service.
To support the Care Transfer Hub Manager (Physical) in prioritising workload and allocating team members and resources.
To promote the use of digital systems to improve sharing of information between teams (internal and external).
Attend board rounds to understand patient needs and champion the "Home First" approach.
To lead multidisciplinary team (MDT) meetings to unblock problems and keep the team on track with focus on where possible getting the patient home, reducing delays in the transfer of care to improve the patient outcomes.
Promote the "Discharge to Assess" model in all patient interactions and MDT discussions and always think why not home, why not today.
About us
You will be working for an organisation which values and respects all of its staff and the community it serves. The Trust is a leader in the NHS and research sectors and provides excellent benefits for its employees. This includes commitments to professional development but also many policies to support employees in balancing their personal and professional lives.
The objective for the team is to lead discharge planning for patients leaving hospital on all pathways and ensuring that as many patients as possible get the support they need to go home. The Care Transfer Hub should be involved with complex patient discharge from early in admission to plan for and mitigate problems.
Job description
Job responsibilities
Please view the attached Job Description and Person Specification documents for full details regarding this post.
When completing your application please ensure that you clearly demonstrate how you meet the role criteria.
Job description
Job responsibilities
Please view the attached Job Description and Person Specification documents for full details regarding this post.
When completing your application please ensure that you clearly demonstrate how you meet the role criteria.
Person Specification
Educational and Qualifications
Essential
- First level Registered General Nurse (with valid NMC registration
- Recognised leadership/ management qualification
- Masters in a health-related subject or currently working towards
- Commitment and evidence of ongoing professional development
- To have completed the national programme for practice assessors or equivalent teaching and assessing qualification for those with ENB998
Experience
Essential
- Extensive post registration experience as a senior nurse including leading and managing wards/services.
- Experience of working in a senior leadership role managing staff and HR issues. This includes roster approval and managing roster budget, managing attendance and other complex HR issues, recruitment and selection, and managing complex change initiatives.
- Experience of managing high quality patient centred services and working as part of an MDT to deliver the service
- Experience and understanding of the complexity of managing services across statutory and non-statutory boundaries
- Proven change management experience and implementing strategic change
- Demonstrate experience of leading in audits, evaluation and producing reports.
Desirable
- Experience of managing a multi-disciplinary workforce
- Experience of managing complex projects/programmes
- Community based working experience
Skills and Knowledge
Essential
- Comprehensive understanding system discharge and working across boundaries of organisations
- Ability to work under pressure and meet competing deadlines
- Ability to contribute effectively to the system wide strategic discharge vision
- IT skills including DATIX and knowledge of Microsoft software packages.
- Ability to analyse activity/financial data.
Desirable
- Experience of strategic development and understanding the effects of implementation/evaluation and review.
- Knowledge of current local and national policies relating to discharge
Personal Qualities
Essential
- Highly motivated and passionate about discharge and the delivery of patient centred care
- A confident and competent decision maker with the ability to work autonomously and as part wider system wide MDT team
- Assertive and confident with evidence of effective communication and interpersonal skills
Person Specification
Educational and Qualifications
Essential
- First level Registered General Nurse (with valid NMC registration
- Recognised leadership/ management qualification
- Masters in a health-related subject or currently working towards
- Commitment and evidence of ongoing professional development
- To have completed the national programme for practice assessors or equivalent teaching and assessing qualification for those with ENB998
Experience
Essential
- Extensive post registration experience as a senior nurse including leading and managing wards/services.
- Experience of working in a senior leadership role managing staff and HR issues. This includes roster approval and managing roster budget, managing attendance and other complex HR issues, recruitment and selection, and managing complex change initiatives.
- Experience of managing high quality patient centred services and working as part of an MDT to deliver the service
- Experience and understanding of the complexity of managing services across statutory and non-statutory boundaries
- Proven change management experience and implementing strategic change
- Demonstrate experience of leading in audits, evaluation and producing reports.
Desirable
- Experience of managing a multi-disciplinary workforce
- Experience of managing complex projects/programmes
- Community based working experience
Skills and Knowledge
Essential
- Comprehensive understanding system discharge and working across boundaries of organisations
- Ability to work under pressure and meet competing deadlines
- Ability to contribute effectively to the system wide strategic discharge vision
- IT skills including DATIX and knowledge of Microsoft software packages.
- Ability to analyse activity/financial data.
Desirable
- Experience of strategic development and understanding the effects of implementation/evaluation and review.
- Knowledge of current local and national policies relating to discharge
Personal Qualities
Essential
- Highly motivated and passionate about discharge and the delivery of patient centred care
- A confident and competent decision maker with the ability to work autonomously and as part wider system wide MDT team
- Assertive and confident with evidence of effective communication and interpersonal skills
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.
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).
Additional information
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.
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).
