Homeless Hospital Discharge Link Worker

Job description

Job responsibilities

• Identification of inpatients who are homeless. This will include people with no fixed abode, people who are at risk of homelessness, and/or people who cannot safely return to their home.
• Supporting people who are homeless, or at risk of homelessness, to have a safe, planned discharge from hospital following an inpatient admission.
• Liaison between Fylde Coast Housing Teams and the Blackpool Teaching Hospitals Bed Flow Team and Emergency Department.
• Reducing inappropriate and preventable admissions and readmissions to both A&E and inpatient wards at Blackpool Victoria Hospital from homeless people.
• Taking referrals from the NWAS frequent caller service for people and who are identified with housing as a contributory factor to their health and social care needs.
• Ensuring the delivery and raising the awareness of the discharge pathway for people who are homeless and ensuring the hospital Duty to Refer team, refer people who are homeless/threatened with homelessness into a Local Authority.
• Supporting appropriate onward referrals and follow-up care.
• Identification of Patients
• Interrogation of systems within Blackpool Victoria Hospital, liaison with FCMS Shift Manager, discharge team, ward staff and undertaking ward visits to identify people who are homeless and in need of support as part of their discharge from Blackpool Victoria Hospital.
• Work collaboratively with Trust colleagues to identify people who are homeless requiring support and who repeatedly attend A&E. Try and prevent patients early unplanned / unsafe discharge from hospital.
• Attend relevant MDT meetings e.g., Fylde Coast Multiple Disadvantage MDT, Multi-Agency Oversight Group etc., to assist in identifying patients in the hospital and to make referrals to local services relevant to the patient e.g., Changing Futures, Oasis, etc.
• Homeless Discharge Communication
• Working with all people who are homeless and admitted to Blackpool Victoria Hospital, developing strong links with Blackpool, Fylde, and Wyre housing teams.
• Undertaking initial needs assessments and liaising with the Fylde Coast housing teams to discuss the identified needs and how these can be met.
• Informing each local authority housing team and out of hours service as required, of possible discharges over the weekend or in the evenings and to liaise with the relevant parties to make arrangements for temporary accommodation.
• For homeless people who repeatedly attend A&E, ensuring the patients are aware of the alternative options for accessing health care.
• Identify 999 Frequent Caller Service, for people who have been identified with housing needs as a contributory factor to their health and social care needs.
• Liaising with Primary care Networks (PCNs) to identity 999 Frequent Callers and Emergency Department and Urgent Care frequent attenders, being mindful of any additional needs the patient may have.
• Liaising with relevant housing departments, to facilitate the discharge of patients who are homeless, or threatened with homelessness, into suitable accommodation whenever possible/ available.
• Maintain the hospital discharge protocol.
• Follow-up with the patient, post discharge, to ensure any agreed support has been implemented.
• Maintain a Housing Options resource pack for staff on A&E and inpatient wards and provide relevant training as required.
• Maintain links with inpatient wards to ensure that any housing issues are identified at the point of admittance and addressed before discharge date.
• Attend meetings with Blackpool Teaching Hospitals and with housing colleagues to support service delivery.
• Attend relevant multi-disciplinary meetings to support patient care.
• Work with the Fylde Coast homeless health team to arrange ongoing support into an individuals health needs following discharge.
• Work with other statutory and voluntary agencies to obtain the best outcome for the service user, liaising with and making referrals as appropriate.
• Ensure all service users in housing need are referred to the Single Point of Access for accommodation where appropriate.
• Reduce hospital admissions and readmissions to both A&E and inpatient wards from homeless households, by working with people who are homeless and frontline staff to identify reasons for admission.
• Support delivery of Blackpool Teaching Hospitals requirements to refer to housing on discharge, where appropriate.
• Ensure that people who are homeless are not discharged to the street following a hospital admission.
• Make referrals to social care for assessment as and when needed.
• Attend the fortnightly Risk Management Meeting, highlighting any patient needs and assisting in identifying people who are frequent attenders of urgent and emergency care services.
• Represent the service at the MAG meeting - Locality Multi-Agency Oversight Group
• Develop relationships with local GP Practices and Primary Care Networks to facilitate support for the patients.
• Facilitate links between Blackpool Victoria Hospital and the relevant substance use provider (Delphi and CGL/ Inspire for Fylde Coast) to support better management of patients who are at an enhanced risk of premature, unplanned self-discharge due to lack of appropriate pain relief for people e.g., patients who are on an Opiate Substitute Programme or who have substance dependence.
• Attendance at meetings and ward rounds, and frequent visits to wards across the Blackpool Victoria Hospital site, to identify and support people who are homeless, is required.
• Contribute to service improvement goals to ensure a positive impact on patient services for patients.
• Contribute to any necessary ongoing development of current protocols, guidance and standard operating procedures as appropriate.
• To work within their own competence, seeking senior advice as/when appropriate
• Work within Trust policies at all times, including the right to reside policy
• To undertake training and awareness raising as required to support successful delivery of the main responsibilities of this role.
• Activity Monitoring
• Complete patient contact notes in the relevant hospital system and the Homeless Health Community Instance of EMIS to provide transparency and to assist in collating reporting data.
• Complete the KPI data for to include:
• o Patient demographic data
• o Patient locality
• o No of people who are homeless or at risk of homeless and have received supported with a safe discharge.
• o Accomodation status
• o How patients are identified
• o Frequent attenders
• o Service promotion
• o Number of onward referrals and who the patient has been referred to.
• o No Duty to Reside data
• o Discharge outcomes including patient destination.
• o Quarterly Case Study
• Develop a monitoring and evaluation mechanism and provide quarterly reports, including in relation to the 999 Frequent Caller Service
• Assist in the collection of statistical information from the hospital, Northwest Ambulance Service (NWAS) and Housing Options using data bases and electronic management systems where appropriate.
• Accurately record advice and outcomes of assessment, care planning and interventions having due regard to legal aspects, confidentiality, and managerial information requirements
• The postholder is expected to work in the interest of the organisation. This may include undertaking other duties that are appropriate to the employees background, skills and abilities. Where this occurs, there will be consultation with the employee.
• Working Relationships
• The main people that the postholder will be expected to communicate with will be:
• Patients, their carers and relatives
• Hospital bed flow team
• Hospital discharge team
• Local authority housing teams in Blackpool, Fylde and Wyre Councils
• MDTs
• Ward-based teams
• Hospital emergency department
• Disabled Facilities Services
• Health and Social Care Commissioners
• Additional Requirements and Skills
• Provide an update report highlighting successes and challenges, for discussion at the Joint Governance meeting between FCMS (NW) Ltd and Blackpool Victoria Hospital.
• Contribute to / complete a Homeless Checklist including Duty to Refer as per the Emergency Department pathway, checklist and toolkit PowerPoint Presentation (england.nhs.uk)
• Frequent requirements for concentration during patient assessment and care provision.
• Frequent requirement for accuracy in assessing patients.
• Frequent requirement for concentration in complex multi-disciplinary meetings.
• Occasional requirement to make difficult decisions to deliver competing demands.

Person Specification

Qualifications

Desirable

• GCSE/O Level English and Maths

ANALYTICAL & JUDGEMENT SKILLS

Essential

• The postholder will need to be able to work autonomously and make decisions that support the best possible outcome for the patient, sometimes without the full details available.

Desirable

• Knowledge of Core20PLUS5, an improvement approach to drive specific action to support the reduction of health inequalities at both national and system level. People experiencing homelessness are more likely to be systematically socially excluded, typically experience multiple overlapping risk factors for poor health, experience stigma and discrimination, and are not consistently accounted for in electronic records.

Experience

Essential

• Experience of working with customers and / or patients with complex needs.
• Direct working experience of delivering a frontline service.
• Working on own initiative and as part of a team (across services).
• Dealing with a diverse clientele.
• Experience of working within a multi-disciplinary environment.
• Working under pressure and meeting deadlines.
• Working in a problem-solving context with a variety of statutory and voluntary agencies
• Managing a caseload.
• Assessment interviewing.

Desirable

• Experience of working on hospital IT systems.
• Experience working in a housing service.
• Mental health awareness.
• Direct experience of working with rough sleepers or those leading an unsettled lifestyle
• Direct experience of working with people with alcohol, drug, mental health problems

Skills, Knowledge & Competencies

Essential

• Knowledge and understanding of the causes of homelessness.
• Knowledge of local homeless services.
• Trauma Informed approached to working with people.
• Ability to write detailed and complex reports.
• Excellent interpersonal skills including verbal and written communication.
• Non-judgemental attitude.
• Ability to remain calm under pressure.
• Excellent IT skills IT is an integral part of the role and will form part of the interview process.
• Excellent organisational skills and the ability to prioritise workloads and meet deadlines.
• Ability to negotiate effectively by presenting key issues in a persuasive and balanced manner, influencing opinion, and resolving deadlocked situations.
• Ability to develop and maintain effective relationships with colleagues, agencies and organisations particularly where there are conflicting agendas.
• Ability to work on own initiative as well as within a team environment (across services), prioritising, making decisions and successfully managing a personal caseload.
• Ability to think laterally, seeking opportunities for improvement.
• Competent, reliable and conscientious person who can work on their own initiative and has the ability to observe confidentiality.
• Flexibility of working hours to support annual leave, sickness and the needs of the business.
• Implement processes and procedures that enable achievement of all aspects of the job description.
• Manage own time to enable achievement of all aspects of the job description.
• Utilise IT programmes to develop presentations, papers and reports to be presented locally as required.
• Active listening to build trust with patients and develop working relationships with the key partners in this job description.
• Be able to (and be able to recognise the need to), modify and adapt methods of communication to account for the differing needs of patients especially in stressful and difficult situations and ensure polite, efficient and appropriate communications exist at all times.

Desirable

• Working knowledge of relevant legislation.
• Working knowledge of the benefit system and how it relates to the client group.
• Understanding of local and national homeless strategies.

Other

Essential

• Belief in our corporate values
• Fun
• Awesome
• Humble
• Brave
• Go-getting
• Oomph
• Self-awareness
• Resilience
• Enthusiastic and positive
• Approachable
• Team Player
• Always aims for excellence.
• Ability to work calmly.
• The post holder must be able to demonstrate a good performance work record.
• Have a flexible approach to working arrangements.
• Current driving licence and use of a car.

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.

Employer details

Employer name

FCMS

Address

Blackpool Victoria Hospital

Whinney Heys Rd

Blackpool

FY3 8NR

Employer's website

http://www.fcms-nw.co.uk/ (Opens in a new tab)