Job summary
The Care Transfer Hub Practitioner is responsible for navigating and coordinating flow across Joined Up Care Derbyshire services by managing referrals through the system Care Transfer Hub. The post holder will take a lead role in assessing an individual's need, triaging referrals and using professional judgement to navigate and coordinate the support needs. The role is pivotal in ensuring people are safely and appropriately transferred between care settings. Working within a multi-agency Care Transfer Hub, the postholder ensures timely and appropriate onward referrals to community health, social care, or voluntary sector services. This role involves clinical triage, multidisciplinary collaboration, and effective communication to avoid delays in hospital discharge and ensure continuity of care. There may be the opportunity to work alongside colleagues within the acute hospital setting as part of the role.
Main duties of the job
o Use experience and knowledge to triage and navigate the future ongoing needs for patients accessing intermediate care pathways from acute or community settings. Work in both a multi-disciplinary and interdisciplinary way to develop timely and person-centred plans based on the home first principles. Promote a strength-based approach to maintain independence and positive risk taking, ensuring adequate support is in place from statutory or voluntary services where required.
o Liaise with health and social care professionals, including district nurses, social workers, therapists and care providers. Participate in, and lead, multidisciplinary meetings (MDTs) and contribute to discharge planning processes.
o Support decision-making around Continuing Healthcare (CHC), reablement, and domiciliary care packages.
o Act as a point of contact for professionals and patients/families regarding transfer of care.
About us
Working for our organisation
Our purpose is to provide community health services to a patient population of over one million people in Derbyshire and Derby, as part of Joined Up Care Derbyshire.
We employ around 4,200 substantive staff, caring for patients in 11 community hospitals and more than 30 health centres, as well as in clinics, GP practices, schools, care homes and, increasingly, in people's own homes and via virtual consultations.
It is an exciting time to join primary care and community services as the national Ageing Well programme gathers pace.
DCHS is working closely with the Primary Care Networks to transform the care of housebound and vulnerable people across Derbyshire through our Team-Up approach
Job description
Job responsibilities
PLEASE NOTE: Please see attached Job Description and Person Specification. To apply, please click APPLY FOR THIS JOB - this link will take you to the TRAC Recruitment Site. You will need to register if you do not already have an account.
Job description
Job responsibilities
PLEASE NOTE: Please see attached Job Description and Person Specification. To apply, please click APPLY FOR THIS JOB - this link will take you to the TRAC Recruitment Site. You will need to register if you do not already have an account.
Person Specification
Qualifications/education
Essential
- Degree/diploma in Physiotherapy/occupational therapy/nursing
- car driver/valid driving licence/access to vehicle
- registration with a professional Body
Experience
Essential
- Current/recent experience clinical senior Band 5 level
- knowledge of community services
- Experience of working with adults in a variety of settings
- knowledge of dealing with and managing complex situations and ability to make decisions
Desirable
- Knowledge of admission and discharge agenda
- Experience of working across organisational boundaries
- Band 6 experience
Skills and Attributes
Essential
- Strong assessment and decision-making skills; ability to work under pressure; excellent communication and IT skills
- Excellent communication skills both written and verbal
- Able to work effectively in the team
- Willingness to undergo further training and development as the job develops
Person Specification
Qualifications/education
Essential
- Degree/diploma in Physiotherapy/occupational therapy/nursing
- car driver/valid driving licence/access to vehicle
- registration with a professional Body
Experience
Essential
- Current/recent experience clinical senior Band 5 level
- knowledge of community services
- Experience of working with adults in a variety of settings
- knowledge of dealing with and managing complex situations and ability to make decisions
Desirable
- Knowledge of admission and discharge agenda
- Experience of working across organisational boundaries
- Band 6 experience
Skills and Attributes
Essential
- Strong assessment and decision-making skills; ability to work under pressure; excellent communication and IT skills
- Excellent communication skills both written and verbal
- Able to work effectively in the team
- Willingness to undergo further training and development as the job develops
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).
