Complex case manager

Job description

Job responsibilities

To actively facilitate effective and timely discharge of patients through liaison with appropriate departments, organisations, and professionals.

Attended the daily ward board rounds of patients on your case load to review patients needs related to discharge and update the ward MDT.

Provide Specialist Knowledge, support, and guidance to colleagues regarding discharge planning and mental capacity.

Demonstrable working knowledge and practical application of legislation relevant to discharge and transfer of care process including the Care Act.

Have extensive knowledge of health and social care services, roles and responsibilities and apply this to support patient discharges.

Liaise with Site Manager to ensure complex discharges are expedite on date of discharge.

To Coordinate / Participate in family, professional, and best interest meetings with multi-agencies to discuss Patients discharge arrangements.

Identify delays in the patient journey and act appropriately to challenge process.

Expert knowledge and understanding of the D2A model and pathways

Be the health lead in understanding the appropriate Discharge to Assess (D2A) pathway appropriate for patients and be ready to facilitate this pathway as soon as the patient is medically optimised.

Responsible for the integrated discharge hub and ensuring patient referrals are forwarded to relevant agencies in a timely manner

Responsible for updating Transfer of Care form (TOC) post IDT Hub with pertinent information identified to support Patients needs for a pathway to be agreed.

Work collaboratively with Specialist Teams internal and external to confirm clinical plans in place to reduce non valued added in-patient days and follow-on care post discharge.

Liaise with General Practitioners, community nurses, clinical support professionals and other agencies to facilitate a patient discharge.

Liaise with the community hospitals to ensure the continuity of patient care, when crossing healthcare boundaries.

Act as a focus for investigations and resolution of individual patient discharge problems, utilising the links with other professionals and an overall knowledge of available facilities and options for patient care within the community.

Support wards to diffuse and deal with conflict and delicate discharge situations to agree a discharge plan.

Clinical:

Responsible for managing a case load of Patients on complex discharge pathways 1, 2, 3 (those requiring health and/or social care and support following discharge) referred via the Integrated Discharge Hub.

Act in accordance with the relevant professional codes i.e., NMC/HCPC

Be a trusted assessor to enable patients to return to their usual place of residence

(24-hour care placement)

Have extensive knowledge within the legal framework of Mental Capacity Act 2005,

Deprivation of Libertys Safeguarding (DOLs) and Power of Attorney (POA) to be able to inform complex discharge planning of patients who lack capacity around future care planning and cannot advocate themselves.

Complete mental capacity assessments to inform discharge planning where appropriate.

Provide specialist discharge advice to Patients / Relatives and ward staff acting as a role model and resource, support, and guidance.

To support ward staff in the identification of possible safeguarding issues arising from the community or regarding discharge planning and to ensure that the ward can escalate these issues in line with trusts safeguarding policy.

Ensure that documentation standards are maintained in accordance with professional body, whether written or computerised.

Communication:

Use a range of verbal or non-verbal communication effectively with professionals, patients, and their carers to progress care and discharge plans in a safe and timely manner

Effectively communicate clinical information that is complex and multi-stranded, including patients physical, mental, and functional impairments and their recovery trajectory as part of a timely, co-ordinated multidisciplinary service

Demonstrate the ability to tactfully communicate highly complex and/or highly sensitive information to a) Patients and their carers and b) members of staff.

Be able to deploy communication skills to de-escalate contentious or potentially hostile situations to resolve disputes in line with the Trusts conflict resolution policy.

Use highly developed interpersonal and persuasion skills to build and maintain working relationships with internal and external agencies for the benefit of patient care quality and organisational performance

Clinical Governance / Quality Improvement:

Contribute to minimising complaints regarding discharge planning by investigating in an appropriate timely way and establish lessons learnt and enact and share the improvements identified

Act as a focus for investigations and resolution of individual patient discharge problems, utilising the links with other professionals and an overall knowledge of available facilities and options for patient care within the community.

To problem solve complex discharge issues liaising with multi-agencies, other professionals, and services to facilitate discharge i.e., Transport, Mental Health, Voluntary Organisations,

Residential and Nursing Homes, Equipment Service, Age Concern, Brain Injury Team and Council Adaptations.

To undertake regular audits of discharge planning practice, processes and delayed discharges as required.

Responsible for identifying evidence-based research to develop own practice and service

To raise awareness if admissions become greater than Stranded recommendations leading to potential outliers/delays.

Education and Training:

Fulfil the requirements as directed by professional body to maintain and revalidate registration to maintain, develop and continually update own specialist knowledge and own competency to practice through Continuous Professional Development (CPD) activities.

To maintain a portfolio, which reflects personal and professional development, complying with your agreed personal development plan.

To provide periodic training and educational input to the multidisciplinary team on the discharge policy, practice, and procedure to improve the quality of the patients experience of hospital discharge, improve patients outcomes and reduce delays in transfer of care.

To provide education to clinical and nursing staff regarding the remit of the Discharge team.

Service Development:

There may be requirement as the service develops for the role to cover a 7 day service.

Person Specification

Educations,Training and Qualifications

Essential

• Degree level education or equivalent demonstrable experience.
• Evidence of further education or study up to master's level or equivalent level of training or experience.
• Recognised teaching or assessing qualification or equivalent demonstrable experience of teaching and assessment.
• Health or Social Care professional registered with a nationally recognised regulatory body NMC, HCPC, Social Work England.
• Evidence of proactive and continued professional development.

Knowledge and Experience

Essential

• Mental and Emotional effort e.g. concentration levels - dealing with patients and relatives regarding sensitive issues concerning discharge, ability to defuse difficult situations, excellent persuasive skills to manage highly emotive situations and overcome barriers to understanding.
• To have a clear working knowledge of the Hospital discharge service: policy and operating model.
• Evidence of competence in CHC, safeguarding, MCA, DOL's.
• Evidence of proactive and continued professional development.
• Significant post registration experience in speciality.
• Recent relevant experience at senior level band 6 or above.
• Knowledge and understanding of the D2A pathways.
• Ability to Assess, Plan and manage the care of a wide variety of patient conditions.
• Experience of dealing with people who display inappropriate behaviours verbal aggression, insensitive and potentially hostile situations.

Desirable

• Understanding of impact of high Stranded numbers.
• Understanding of impact of delays in discharging patients.

Skills

Essential

• Ability to prioritise and demonstrate time management and organisational skills.
• Ability to work under pressure and change tasks daily to support Trust OPEL status or interject to ensure actions are followed up on request by Site Team, Senior Managers, Matrons.
• Demonstrate the ability to obtain and evaluate information to aid decision making and to develop others in this area.
• Highly developed communication skills, written, verbal and presentation, able to give constructive feedback.
• Demonstrate a good understanding of wider health and social care systems.
• Understanding of clinical governance and its application.
• Ability to cope with a range of complex options, find solutions, analyse, compare, and decide appropriate course of action.
• IT literate frequent use of VDU equipment, capable of using and interrogating IT data systems in support of the discharge role.

Key Competencies, Personal Qualities and Attributes

Essential

• Passionate and committed to bring our Dedicated to Excellence values to life, improving the way we work with each other, particularly focusing on empowerment, equality diversity and inclusion of our staff, patients, and service users.
• Flexible and adaptable for the changing needs of the service.
• Innovative, good team player, Leadership skills, Motivated and Positive, Professionalism, Problem Solving, Conflict resolution and Caring, Compassionate.

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).

Employer details

Employer name

Northampton General Hospital

Address

Northampton General Hospital

Cliftonville

Northampton

NN1 5BD

Employer's website

https://www.northamptongeneral.nhs.uk/Home.aspx (Opens in a new tab)