Job summary
We are looking for candidates to join our expanding Integrated Discharge (IDS) team and support the development of the Transfer of Care Hub.
You will be crucial in ensuring that patients get to go home through a timely, safe, and effective discharge process.
This patient-facing role involves discussions with patients and their families and liaising and co-ordinating with multiple teams across the Trust and partners across Bristol, North Somerset and South Gloucestershire (BNSSG). This allows us to ensure patients are discharged from the hospital at the earliest opportunity and that beds are available to those that need them.
Candidates should have the following skills and experience
- Educated to GCSE standard to include English
- IT skills, basic word, email, keyboard skills, data collection
- Able to manage conflicting demands
- Confidence to engage with multiple professionals
- Adaptable to changing operational requirements
- Previous knowledge of patient admin systems- e.g. CareFlow Connect/ EMIS
- Previous knowledge of care work or of clinical environment (desirable)
Full training and support will be given as required.
Main duties of the job
In this vital role, you will:
- Workin partnership with other members of theIntegrated Discharge Service (IDS), WardMulti-DisciplinaryTeam (MDT) and Communitypartners,to support decisions with regards to discharge planning
- Represent the IDS team at ward daily board rounds
- Provide effective & timely communication of discharge actions using existing communication tools
- Be expected to undertake a range of duties without direct supervision but will be required to report back on those delegated duties to the ward team and case manager
- Work across multi- professional disciplines and make referrals for additional assessmentsand treatmentsas required, supported by the case manager
About us
NBT Cares
It's a very simple statement; one which epitomises how everybody across our organisation goes the extra mile to ensure our patients get the best possible care.
NBT Cares is also an acronym, standing for caring, ambitious, respectful and supportive - our organisational values.
And our NBT Cares values are underpinned by our positive behaviours framework - a framework that provides clear guidance on how colleagues can work with one another in a constructive and supportive way.
Patients are the most important people in the health service and are at the centre of what we do. Patients and carers are the 'experts' in how they feel and what it is like to live with or care for someone with a particular illness or condition. The patients' experience of our services should guide the way we deliver services and influence how we engage with patients every day in our work.
All staff should communicate effectively in their day to day practice with patients and should support and enable patients/carers to make choices, changes and influence the way their treatment or care is provided. All staff, managers and Board members should work to promote effective patient, carer and public involvement in all elements of their work
Job description
Job responsibilities
- To have early conversations with patients and families/ carers around discharge and use this information to support the persons journey whist in hospital, adhering to the Home First discharge ethos
- Supporting and working in partnership with other members of the Integrated Discharge Service (IDS), Ward Multi-Disciplinary Team (MDT) and Community partners, constructively challenging where appropriate, the decisions with regards to discharge planning
- Be an active member of the newly formed Transfer of Care Hub (ToCH)
- Undertake baseline assessments in partnership with other members of the MDT ensuring that the admission and social assessments are available within 24 hours of the admission
- Prompt the MDT to always ensure the patient and their family are actively involved in their discharge planning and are always kept informed any updates or changes to the plans
- Represent the Integrated Discharge Service (IDS) at ward daily board rounds and actively participate to drive timely discharge
- Provide effective & timely communication of discharge actions, including action owners and timeframes with MDT team members and Case Managers and liaise with the nurse in charge/coordinator and consultant to update on actions required to expedite safe discharge.
- Meet daily with the Case Manager for the allocated Cluster to review patient progress and escalate concerns
- Post holder will escalate problems in discharge to the case manager or ward team as appropriate.
- Recognise the need for and undertake referrals to specialist practitioners/ therapists as appropriate.
- Participate & support case managers in ward education programmes to develop knowledge and understanding of complex discharge management including Single Referral Forms (SRF) completion and managing patient expectations.
- Support ward teams to ensure that Flow Board information is up to date at all times and any changes are modified in a timely a manner when needed e.g. not only updated at board rounds
- The post holder will ensure patients and carers are aware of their Estimated Date of Discharge (EDD).
- Provide patients with written discharge related information e.g. Trust Discharge leaflet, pathway specific leaflets etc as appropriate
- Demonstrate a variety of communication skills in accordance with the patient group
- Support ward MDT colleagues to populate the Transfer of Care Documents (ToC Docs) & Continuing Health Care (CHC) referrals
- Support ward MDT colleagues to review Transport requests & check bookings made at the earliest opportunity
- Review patient Criteria to Reside (C2R) coding with ward staff, case manager & integrated discharge team and assist in updating the information, as appropriate
- Liaise with Care Homes / Home Care providers to ensure timely ward assessments and plan transfer when accepted by the provider
- Liaise with the IDS admin team and ensure that they are aware of all known planned complex discharges
- Maintain clear concise patient records and documentation adhering to the Hospital Discharge and Community Support: Policy and Operating Model and other Trust policies and procedures.
- Provide concise handovers to other members of the MDT and escalate any delays in patient discharge to the Cluster Case Manager
Job description
Job responsibilities
- To have early conversations with patients and families/ carers around discharge and use this information to support the persons journey whist in hospital, adhering to the Home First discharge ethos
- Supporting and working in partnership with other members of the Integrated Discharge Service (IDS), Ward Multi-Disciplinary Team (MDT) and Community partners, constructively challenging where appropriate, the decisions with regards to discharge planning
- Be an active member of the newly formed Transfer of Care Hub (ToCH)
- Undertake baseline assessments in partnership with other members of the MDT ensuring that the admission and social assessments are available within 24 hours of the admission
- Prompt the MDT to always ensure the patient and their family are actively involved in their discharge planning and are always kept informed any updates or changes to the plans
- Represent the Integrated Discharge Service (IDS) at ward daily board rounds and actively participate to drive timely discharge
- Provide effective & timely communication of discharge actions, including action owners and timeframes with MDT team members and Case Managers and liaise with the nurse in charge/coordinator and consultant to update on actions required to expedite safe discharge.
- Meet daily with the Case Manager for the allocated Cluster to review patient progress and escalate concerns
- Post holder will escalate problems in discharge to the case manager or ward team as appropriate.
- Recognise the need for and undertake referrals to specialist practitioners/ therapists as appropriate.
- Participate & support case managers in ward education programmes to develop knowledge and understanding of complex discharge management including Single Referral Forms (SRF) completion and managing patient expectations.
- Support ward teams to ensure that Flow Board information is up to date at all times and any changes are modified in a timely a manner when needed e.g. not only updated at board rounds
- The post holder will ensure patients and carers are aware of their Estimated Date of Discharge (EDD).
- Provide patients with written discharge related information e.g. Trust Discharge leaflet, pathway specific leaflets etc as appropriate
- Demonstrate a variety of communication skills in accordance with the patient group
- Support ward MDT colleagues to populate the Transfer of Care Documents (ToC Docs) & Continuing Health Care (CHC) referrals
- Support ward MDT colleagues to review Transport requests & check bookings made at the earliest opportunity
- Review patient Criteria to Reside (C2R) coding with ward staff, case manager & integrated discharge team and assist in updating the information, as appropriate
- Liaise with Care Homes / Home Care providers to ensure timely ward assessments and plan transfer when accepted by the provider
- Liaise with the IDS admin team and ensure that they are aware of all known planned complex discharges
- Maintain clear concise patient records and documentation adhering to the Hospital Discharge and Community Support: Policy and Operating Model and other Trust policies and procedures.
- Provide concise handovers to other members of the MDT and escalate any delays in patient discharge to the Cluster Case Manager
Person Specification
Essential and Desirable
Essential
- Educated to GCSE standard to include English
- IT Literate
- Ability to communicate effectively with a range of partners
- Able to work effectively as part of a team but also under own initiative
- Able to manage own workload and conflicting demands
Desirable
- NVQ Level 3 Health and Social Care
- Previous experience in an acute clinical environment
- Excellent organisational skills
Person Specification
Essential and Desirable
Essential
- Educated to GCSE standard to include English
- IT Literate
- Ability to communicate effectively with a range of partners
- Able to work effectively as part of a team but also under own initiative
- Able to manage own workload and conflicting demands
Desirable
- NVQ Level 3 Health and Social Care
- Previous experience in an acute clinical environment
- Excellent organisational 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).
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).
