Job summary
The Discharge team is seeking to appoint a Discharge Facilitator on a full-time, permanent basis. You will be responsible for providing specialist advice and support to the wards and their multi-professional teams in managing effective patient discharge as an integral part of care management.
You will also work with systems partners in the community and social care, providing comprehensive assessment plans to support safe discharge. Lastly, you will be responsible for supporting and participating in the readmissions prevention and management schemes, as well as training and developing ward staff to ensure best practice in planning safe and timely patient discharges in order to achieve best outcomes for patients, to optimise hospital bed utilisation and reduce length of stay.
This post is open to NMC Registered Nurses, Qualified Social Workers, and Qualified Therapists.
Main duties of the job
- Attend daily Patient placement meetings, giving current information of the trust discharge position for any PW1,2 or 3 delays
- To work closely with the Site team to unblock any discharge/transport issues that may impede discharge
- Take a lead role in identifying patients who require the services provided by the Transfer of care team
- To work in collaboration with community partners to plan and manage timely and appropriate transfers of care (discharge) for patients from the hospital.
- To attend nominated wards on a daily basis, to negotiate and support transfer of care arrangements for patients
- Identify and initiate specialist assessments of patients for NHS Funded Continuing Health Care in line with Government policy and eligibility criteria, and present cases to the Continuing to the Continuing Health Care Panel when required
- To lead/organise and be actively involved in case conferences, as appropriate.
- To be aware of changes in legislation and processes, including NHS Continuing Care that may influence the outcome of transfer of care for all client groups and ensure the trusts current policies and procedures follow any changes in legislation.
- To develop and maintain links with community health providers and other services which facilitate discharges and provide a consistent point of contact within the Trust for these services.
- To identify patients that meet the fast track criteria and ensure the patients place of choice is considered
About us
The discharge team are a mix of clinical and administration staff. The service runs 7 days a week in office hours.
The team comprises of a Matron, 3 discharge facilitators, 4 discharge support nurses, a voluntary discharge coordinator, an assistant service manager and 3 transfer of care coordinators
Benefits include networking with a large diverse team which includes internal and external partners.
In house training courses, access to Alex Lounge which is a staff only rest area with free tea and coffee
Job description
Job responsibilities
- To actively participate in and investigate complaints which specifically involve a transfer of care process issue.
- To maintain accurate and contemporaneous records relating to individual patient transfers of care.
- In collaboration with professional colleagues to proactively manage and negotiate complex transfers of care e.g. social care packages and appropriate placements and care for disadvantaged patients e.g. the homeless. Other relevant issues e.g. on-going care, convalescence, rehabilitation and respite/ interim repatriation.
- Responsible for the risk stratification, assessment and coordination of discharge plans for patients are deemed as readmissions or at high risk of readmissions.
- Responsible for case management of patients with a long length of stay, facilitate and educate knowledge of the multi-disciplinary team with regard to length of stay of complex cases
- To provide cover for the other discharge nurse specialists as required.
- To work within the Transfer of care team, attend and participate in the team meetings.
- To deputise and attend Trust and other management meetings for the Discharge Matron as required.
- To provide skilled evidence-based care, ensure all care planning is patient centred, dynamic and in accordance with Trusts policies and guidelines.
- To demonstrate an analytical approach to clinical assessment of patients in the light of current research and resources.
- Identify and assess patients for suitable and safe transfer to community/social services beds or intermediate care.
- To promote and support patient advocacy, choice and self-empowerment and encourage patient independence, ensuring full engagement in decisions regarding their future care needs.
- Work in partnership with Social Services Departments to conduct joint assessments and promote understanding of roles as appropriate.
- Provide a resource point and contribute to the development and delivery of education and training programmes for acute by working closely with the education facilitator within the team.
- Training and Development.
- Responsible for leading, developing and delivering the trust discharge teaching/training programmes at Directorate and ward level to ensure best practice in accordance with Princess Alexandras Discharge Policy, whilst ensuring that educational opportunities are maximised in order to develop transfer of care planning skills in others.
- To work as an effective member of the Transfer of Care Team, maintaining personal and professional development and contribute to the development of the team and its activities.
- To participate in Directorate research and education relating to practice.
- To maintain own professional and personal registration and revalidation
- Lead teaching programmes with all Trust staff to ensure best practice in planning safe and timely patient discharges.
- Accountable for his/her practice and takes every reasonable opportunity to sustain and improve his/her knowledge and professional competence.
- To participate in the teaching programmes of learners in accordance with their objectives, working closely with the College/University Develop knowledge and practice in all aspects of patient discharges and long-term care arrangements.
- To be a mentor/preceptor as necessary. Access professional support through clinical supervision.
- To contribute to induction of new hospital employees from all disciplines.
- Provide discharge planning training programmes and oversee training issues across the Trusts to ensure all professional needs are met, thus ensuring the Trusts discharge policies are adhered to.
- Involvement in helping to co-ordinate and review strategy for the Transfer of Care Team and annually assist in reviewing the Discharge Policy and Procedure
- Participate in project work for service improvement
- Leadership
- Supervise and support the continuous development of team members.
- Participate in the Trust appraisal process to ensure that you receive and give constructive feedback to enhance personal skill set and the promotion of professional Integrated Hospital Transfer of Care Team.
- Act as a role model to staff on the ward and throughout the Trust by ensuring you demonstrate the trust values and behaviours and provide teaching and coaching to junior staff.
- Seek and provide supervision to ensure that personal clinical practice is continuously developing.
- Actively participate in the recruitment and selection process for new posts within the Transfer of care team
- Lead the management of authorised leave within your small team including the managing of annual leave, study leave and sickness; to ensure that there is sufficient wider team coverage
- Complete the local induction process for any new team members.
- Provide leadership, support and guidance to staff in their probationary period completing relevant HR processes and paperwork to enable staff to progress.
- To carry out any other duties commensurate with the post.
Job description
Job responsibilities
- To actively participate in and investigate complaints which specifically involve a transfer of care process issue.
- To maintain accurate and contemporaneous records relating to individual patient transfers of care.
- In collaboration with professional colleagues to proactively manage and negotiate complex transfers of care e.g. social care packages and appropriate placements and care for disadvantaged patients e.g. the homeless. Other relevant issues e.g. on-going care, convalescence, rehabilitation and respite/ interim repatriation.
- Responsible for the risk stratification, assessment and coordination of discharge plans for patients are deemed as readmissions or at high risk of readmissions.
- Responsible for case management of patients with a long length of stay, facilitate and educate knowledge of the multi-disciplinary team with regard to length of stay of complex cases
- To provide cover for the other discharge nurse specialists as required.
- To work within the Transfer of care team, attend and participate in the team meetings.
- To deputise and attend Trust and other management meetings for the Discharge Matron as required.
- To provide skilled evidence-based care, ensure all care planning is patient centred, dynamic and in accordance with Trusts policies and guidelines.
- To demonstrate an analytical approach to clinical assessment of patients in the light of current research and resources.
- Identify and assess patients for suitable and safe transfer to community/social services beds or intermediate care.
- To promote and support patient advocacy, choice and self-empowerment and encourage patient independence, ensuring full engagement in decisions regarding their future care needs.
- Work in partnership with Social Services Departments to conduct joint assessments and promote understanding of roles as appropriate.
- Provide a resource point and contribute to the development and delivery of education and training programmes for acute by working closely with the education facilitator within the team.
- Training and Development.
- Responsible for leading, developing and delivering the trust discharge teaching/training programmes at Directorate and ward level to ensure best practice in accordance with Princess Alexandras Discharge Policy, whilst ensuring that educational opportunities are maximised in order to develop transfer of care planning skills in others.
- To work as an effective member of the Transfer of Care Team, maintaining personal and professional development and contribute to the development of the team and its activities.
- To participate in Directorate research and education relating to practice.
- To maintain own professional and personal registration and revalidation
- Lead teaching programmes with all Trust staff to ensure best practice in planning safe and timely patient discharges.
- Accountable for his/her practice and takes every reasonable opportunity to sustain and improve his/her knowledge and professional competence.
- To participate in the teaching programmes of learners in accordance with their objectives, working closely with the College/University Develop knowledge and practice in all aspects of patient discharges and long-term care arrangements.
- To be a mentor/preceptor as necessary. Access professional support through clinical supervision.
- To contribute to induction of new hospital employees from all disciplines.
- Provide discharge planning training programmes and oversee training issues across the Trusts to ensure all professional needs are met, thus ensuring the Trusts discharge policies are adhered to.
- Involvement in helping to co-ordinate and review strategy for the Transfer of Care Team and annually assist in reviewing the Discharge Policy and Procedure
- Participate in project work for service improvement
- Leadership
- Supervise and support the continuous development of team members.
- Participate in the Trust appraisal process to ensure that you receive and give constructive feedback to enhance personal skill set and the promotion of professional Integrated Hospital Transfer of Care Team.
- Act as a role model to staff on the ward and throughout the Trust by ensuring you demonstrate the trust values and behaviours and provide teaching and coaching to junior staff.
- Seek and provide supervision to ensure that personal clinical practice is continuously developing.
- Actively participate in the recruitment and selection process for new posts within the Transfer of care team
- Lead the management of authorised leave within your small team including the managing of annual leave, study leave and sickness; to ensure that there is sufficient wider team coverage
- Complete the local induction process for any new team members.
- Provide leadership, support and guidance to staff in their probationary period completing relevant HR processes and paperwork to enable staff to progress.
- To carry out any other duties commensurate with the post.
Person Specification
Essential
Essential
- RGN with a degree in health related subject and demonstrate relevant experience of working at post degree level
- Innovative, proactive, resourceful and self motivated with a good understanding of IT and systems
- Ability to meet the fundamental aspects of the role and be able to work flexibly to provide 24/7 cover where required
- Ability to organise and prioritise work and act as a role model embracing the responsibilities of being a mentor for band 6 discharge support nurses
- Ability to problem solve, resolve issues and queries locally and escalate where appropriate to the Transfer of Care Matron
- Excellent communication skills and an appetite to develop personal skills and knowledge
- Excellent Communication Skills and manage the workload and adapt to the changing needs and priorities of patients, colleagues and the bigger organisation on a daily basis depending on the pressure experienced.
Desirable
- Strong character and the ability to challenge and motivate
- A good sense of humour and good work life balance ability
- Experience of working within an acute NHS setting
Essential
Essential
- RGN with a degree in health related subject and demonstrate relevant experience of working at post degree level.
- Innovative, pro-active, resourceful and self-motivated with a good understanding of IT and systems.
- Ability to meet the fundamental aspects of the role. And be able to work flexibly to provide 24/7 cover where required
- Ability to problem solve, and resolve issues and queries locally, and escalate where appropriate to the Transfer of Care Matron
- Excellent Communication Skills and manage the workload and adapt to the changing needs and priorities of patients, colleagues and the bigger organisation on a daily basis depending on the pressure experienced.
- Ability to organise and prioritise work and act as a role model embracing the responsibilities of being a mentor for band 6 discharge support nurses
Desirable
- Experience of working in an acute NHS setting
- Strong character and the ability to challenge and motivate
- A good sense of humour and good work life balance ability
Person Specification
Essential
Essential
- RGN with a degree in health related subject and demonstrate relevant experience of working at post degree level
- Innovative, proactive, resourceful and self motivated with a good understanding of IT and systems
- Ability to meet the fundamental aspects of the role and be able to work flexibly to provide 24/7 cover where required
- Ability to organise and prioritise work and act as a role model embracing the responsibilities of being a mentor for band 6 discharge support nurses
- Ability to problem solve, resolve issues and queries locally and escalate where appropriate to the Transfer of Care Matron
- Excellent communication skills and an appetite to develop personal skills and knowledge
- Excellent Communication Skills and manage the workload and adapt to the changing needs and priorities of patients, colleagues and the bigger organisation on a daily basis depending on the pressure experienced.
Desirable
- Strong character and the ability to challenge and motivate
- A good sense of humour and good work life balance ability
- Experience of working within an acute NHS setting
Essential
Essential
- RGN with a degree in health related subject and demonstrate relevant experience of working at post degree level.
- Innovative, pro-active, resourceful and self-motivated with a good understanding of IT and systems.
- Ability to meet the fundamental aspects of the role. And be able to work flexibly to provide 24/7 cover where required
- Ability to problem solve, and resolve issues and queries locally, and escalate where appropriate to the Transfer of Care Matron
- Excellent Communication Skills and manage the workload and adapt to the changing needs and priorities of patients, colleagues and the bigger organisation on a daily basis depending on the pressure experienced.
- Ability to organise and prioritise work and act as a role model embracing the responsibilities of being a mentor for band 6 discharge support nurses
Desirable
- Experience of working in an acute NHS setting
- Strong character and the ability to challenge and motivate
- A good sense of humour and good work life balance ability
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.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
