Job summary
The role will provide support to the frailty, dementia and discharge services. The Integrated Care Coordinator will be based within the urgent care areas completing agreed assessments to support the coordination of care and discharge to enable a reduction in length of stay, reduction in readmission and increase the quality of discharge planning whilst supporting members of the MDT team.
The Integrated Care coordinator will track the progress of patients through their hospital journey and will develop robust plans to facilitate timely discharge, support admission avoidance and reduce readmission.
Main duties of the job
A key part of the role will be liaising with departments/services internally, and across the health economy, who are involved in providing care to patients whilst in hospital and beyond discharge into the community.
This will involve developing excellent working relationships across the health boundaries, and with patient and their families.
The Integrated Care Coordinator will check and challenge internal processes and decisions and will escalate issues which could cause a delay in either treatment or discharge escalating these delays accordingly. Negotiation with staff, services and patients will be a vital part of this role to ensure the patient journey is progressed appropriately and safely.
The Integrated Care Coordinator is responsible for undertaking referrals via Cerner and will complete and track referrals to relevant services to enable further assessment, treatment or discharge planning to take place at the correct stage in the patient's hospital journey.
About us
About the Trust
Chelsea and Westminster Hospital NHS Foundation Trust provide services from two main hospitals, Chelsea and Westminster Hospital and West Middlesex University Hospital, and a number of clinics across London and the South-East.
We have nearly 7,000 members of staff that arePROUD to Carefor nearly one million people.Both hospitals provide full clinical services, including full maternity, emergency and children's,in addition to a range of community-based services across London, such as award-winning sexual health and HIV clinics.
We're one of the best performing Trusts in the country. We're also one of the top trusts to work for -our staff says they're engaged, motivated, and would recommend us as a place to work and receive treatment. Our Trust has been rated by the Care Quality Commission as 'Good' in all five of the main domains of safe, effective, caring, responsive and well-led, giving an us overall rating of 'Good'. We've also been awarded an'Outstanding' rating for 'use of resources' by an NHS Improvement inspection.
Our facilities are some of the best in the country. We have been investing significant Capital year on year in our estate. We have recently completed a £30m expansion of our adult and neonatal critical care facilities at Chelsea and Westminsterand are planning an ambitious £60m development of an Ambulatory Diagnostics Centre at West Middlesex.
Job description
Job responsibilities
To provide a proactive and continuous approach to case finding, assessment and discharge planning. This will involve the continual prioritisation of workload to ensure all cases are managed in a timely manner.
As a member of the frailty team, working autonomously within urgent care, implementing policies and following standard operating procedures (SOPs) relating to the frailty, dementia and discharge of patients. This includes maintaining awareness of best practices and evidence-based interventions.
To communicate with staff within the Trust and external organisations, regularly following up, challenging and negotiating the timeliness of referrals and the prioritisation of further treatment planning by others. Internally, this will include working with registered nurses, physicians, physiotherapists, occupational therapists, social workers, and pharmacists to coordinate assessment and discharges daily, liaising with staff for completion of assessment, treatment plans, discharge summaries and linking in with pharmacy for timely discharge medication.
To actively take part on board rounds within urgent care updating patients Anticipated Date of Discharge (ADD) highlighting internal and external delays contributing ideas in new ways of working to minimise delays in the future. To plan, and transfer patients safely to other departments and wards as requested.
Job description
Job responsibilities
To provide a proactive and continuous approach to case finding, assessment and discharge planning. This will involve the continual prioritisation of workload to ensure all cases are managed in a timely manner.
As a member of the frailty team, working autonomously within urgent care, implementing policies and following standard operating procedures (SOPs) relating to the frailty, dementia and discharge of patients. This includes maintaining awareness of best practices and evidence-based interventions.
To communicate with staff within the Trust and external organisations, regularly following up, challenging and negotiating the timeliness of referrals and the prioritisation of further treatment planning by others. Internally, this will include working with registered nurses, physicians, physiotherapists, occupational therapists, social workers, and pharmacists to coordinate assessment and discharges daily, liaising with staff for completion of assessment, treatment plans, discharge summaries and linking in with pharmacy for timely discharge medication.
To actively take part on board rounds within urgent care updating patients Anticipated Date of Discharge (ADD) highlighting internal and external delays contributing ideas in new ways of working to minimise delays in the future. To plan, and transfer patients safely to other departments and wards as requested.
Person Specification
Required
Essential
- Literacy and numeracy qualifications equivalent to functional skills level 1 or above (e.g., GCSE grade E or above)
- NVQ Level 3 or equivalent in health-related area
- Understanding of the role of Health Care Support Worker
- Ability to work effectively on an individual basis and as part of a multidisciplinary team
- Good written and communication skills
- Ability to evidence / demonstrate key values and behaviours in line with Trust framework
- Flexible in approach to work - must be able to undertake shift work where required
- Experience of inputting to databases, spreadsheets, data management and use of computer systems
- Knowledge of taking clinical observations and assessments
- Understanding the requirements of Patient Confidentiality
- Excellent organisational skills
- Able to use own initiative to plan and prioritise workload to meet deadlines and make decisions in line with competencies
Desirable
- Experience of working with frail or elderly people, with physical/cognitive/mental health disabilities
- Experience of working with patients and carers in a public sector environment
- Experience of working in a health care environment such as the NHS
- Experience supporting volunteers
- Experience working as a member of a discharge or admission avoidance team or equivalent role
- Recognise the importance of the fundamentals of care
- Recognise rehabilitation principles and enabling patients to optimise independence
- Knowledge of hospital systems
Person Specification
Required
Essential
- Literacy and numeracy qualifications equivalent to functional skills level 1 or above (e.g., GCSE grade E or above)
- NVQ Level 3 or equivalent in health-related area
- Understanding of the role of Health Care Support Worker
- Ability to work effectively on an individual basis and as part of a multidisciplinary team
- Good written and communication skills
- Ability to evidence / demonstrate key values and behaviours in line with Trust framework
- Flexible in approach to work - must be able to undertake shift work where required
- Experience of inputting to databases, spreadsheets, data management and use of computer systems
- Knowledge of taking clinical observations and assessments
- Understanding the requirements of Patient Confidentiality
- Excellent organisational skills
- Able to use own initiative to plan and prioritise workload to meet deadlines and make decisions in line with competencies
Desirable
- Experience of working with frail or elderly people, with physical/cognitive/mental health disabilities
- Experience of working with patients and carers in a public sector environment
- Experience of working in a health care environment such as the NHS
- Experience supporting volunteers
- Experience working as a member of a discharge or admission avoidance team or equivalent role
- Recognise the importance of the fundamentals of care
- Recognise rehabilitation principles and enabling patients to optimise independence
- Knowledge of hospital systems
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).
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).