Job summary
The role is to support the coordination of patient
discharges from SaSH to 5 Primary Care Network Anticipatory Hubs (including Urgent Response Team URT
and other Pathways) across East Surrey. The IDT Discharge Coordinator will support the Integrated
Discharge Team in discharging patients back to their homes,
rehabilitation homes/hospitals and care homes. Their aim is to support a reduction in admission, allow a safe discharge
and reduce discharge time frames.
Integrated Discharge Team (IDT)
The Integrated Discharge Team is based in East Surrey
Hospital Redwood Annex and consists of:
- East Surrey Hospital Discharge Coordinator Team
- Surrey County Council Hospital Social Work
- West Sussex County Council Hospital Social Work Team
- First Community Health & Care Trust
- Sussex Community Foundation Trust
- Red Cross
- SaSH at Home
- Surrey & Borders Psychiatric Liaison Service
- Learning Disability Teams for Surrey & Sussex
- Dementia Team
Anticipatory Care Hubs (ACH)
The Anticipatory
Care Hubs work alongside Primary Care Networks covering multiple GP Practices. The team typically consists
of a Frailty GP, Community Matrons, Physician Associates, Clinical Pharmacists,
Care & Link Worker Coordinators. The
teams support the care and coordination for reactive and proactive referrals
for patients over the age of 65, who are frail, have multiple comorbidities,
polypharmacy including those identified as high risk of falls, people with
multiple hospital admissions or recent admission, isolated or homeless people.
Main duties of the job
- To work within the Integrated Discharge Team supporting
the identification of patients for Discharge, which may include patients who
are frail, elderly or have multiple comorbidities which are appropriate for the
input from an Anticipatory Care Hub.
- Liaise with the Anticipatory Care Hub (ACH) Care
Coordinators, and sending electronic discharge lists and Patient Pathway
Referral Forms (PPRF).
- Ensuring patient RESPECT forms are up to date
and informing Anticipatory Care Hub Coordinators of any changes.
- Liaise regularly with the rehabilitation teams
at Caterham Dene Hospital and other rehabilitation establishments.
- Maintain a good level
of communication with the Anticipatory Care Hubs and respond to enquiries
raised in a timely and effective manner.
About us
Alliance
for Better Care CIC is a GP Federation that unites 47 NHS GP practices across
12 Primary Care Networks in Sussex and Surrey. We support our Primary Care
colleagues as well as their patients, to transform how healthcare is managed
within the community.
As a membership organisation, our focus is to work in partnership with our
members and help them to improve the provision of General Practices in the
local area.
We work with and listen to our GP Practices, PCNs, Hospitals, Community
Organisations and the Third Sector. These vital partnerships ensure that,
together, we deliver a truly integrated approach that offers the support and
expertise needed to effectively serve our communities.
Job description
Job responsibilities
Primary
duties and areas of responsibility
- Attend the Integrated
Discharge Team daily meetings along with the Matrons, Red Cross, Fast Track
Coordinator, Social Care, Mental Health Team and Dementia Service to discuss
the medical input for Pathway 1 and 2 (Rehabilitation and Reablement/ICT).
- Attend all meetings
deemed appropriate for the scope of this role.
- Work with the Integrated
Discharge team to support the completion of the Patient Pathway Referral Forms
(PPRF).
- Maintain
relationships with the Multidisciplinary Admissions Avoidance Team (MAAT) and
liaise with them on a regular basis.
- Liaise with Geriatricians, Older Persons Assessment
and Liaison (OPAL) Nurse and the SASH Discharge Coordinator regularly.
Record
Keeping and General Responsibilities
- To maintain accurate and up-to-date records of
contact with patients, carers and professionals, including the use of Cerner/GP
databases such as EMIS/SystmOne, the IDT tracker and the Criteria to Reside
lists.
- To collect data in a prescribed format as
required, in order to demonstrate the impact of the service.
- Report back all failed discharge and significant
events raised by the Anticipatory Care Hubs to the Integrated Discharge Teams
and to the wards within SaSH.
- To actively engage with the practice teams
within the PCNs, ensure effective liaison with all PCN staff and contribute to
the overall aims of the PCNs.
Miscellaneous
- Work as part of the team to seek feedback,
continually improve the service and contribute to business planning.
- Undertake any tasks consistent with the level of
the post and the scope of the role, ensuring that work is delivered in a timely
and effective manner.
- Duties may vary from time to time, without
changing the general character of the post or the level of responsibility.
- On occasions supporting the ABC Anticipatory
Care Teams in a Care Coordination capacity if required.
Please see the full Job Description for further information.
Job description
Job responsibilities
Primary
duties and areas of responsibility
- Attend the Integrated
Discharge Team daily meetings along with the Matrons, Red Cross, Fast Track
Coordinator, Social Care, Mental Health Team and Dementia Service to discuss
the medical input for Pathway 1 and 2 (Rehabilitation and Reablement/ICT).
- Attend all meetings
deemed appropriate for the scope of this role.
- Work with the Integrated
Discharge team to support the completion of the Patient Pathway Referral Forms
(PPRF).
- Maintain
relationships with the Multidisciplinary Admissions Avoidance Team (MAAT) and
liaise with them on a regular basis.
- Liaise with Geriatricians, Older Persons Assessment
and Liaison (OPAL) Nurse and the SASH Discharge Coordinator regularly.
Record
Keeping and General Responsibilities
- To maintain accurate and up-to-date records of
contact with patients, carers and professionals, including the use of Cerner/GP
databases such as EMIS/SystmOne, the IDT tracker and the Criteria to Reside
lists.
- To collect data in a prescribed format as
required, in order to demonstrate the impact of the service.
- Report back all failed discharge and significant
events raised by the Anticipatory Care Hubs to the Integrated Discharge Teams
and to the wards within SaSH.
- To actively engage with the practice teams
within the PCNs, ensure effective liaison with all PCN staff and contribute to
the overall aims of the PCNs.
Miscellaneous
- Work as part of the team to seek feedback,
continually improve the service and contribute to business planning.
- Undertake any tasks consistent with the level of
the post and the scope of the role, ensuring that work is delivered in a timely
and effective manner.
- Duties may vary from time to time, without
changing the general character of the post or the level of responsibility.
- On occasions supporting the ABC Anticipatory
Care Teams in a Care Coordination capacity if required.
Please see the full Job Description for further information.
Person Specification
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care
Knowledge & Skills
Essential
- Excellent IT skills including Excel
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Commitment to collaborative working with all local agencies
- Able to work with others and find creative solutions to community issues
- Demonstrates personal accountability, emotional resilience and works well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and oral communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Knowledge of General Practice (GP) or Hospital systems
Qualifications
Essential
- Demonstrable commitment to professional and personal development
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards
Personal Qualities & Attributes
Essential
- Ability to listen, empathise with people and provide person- centred support in a non-judgemental way
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from all communities
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess/manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the role e.g., when there is a mental health need requiring a qualified practitioner
Person Specification
Experience
Desirable
- Experience of working directly in either the NHS or Adult Social Care
Knowledge & Skills
Essential
- Excellent IT skills including Excel
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- Commitment to collaborative working with all local agencies
- Able to work with others and find creative solutions to community issues
- Demonstrates personal accountability, emotional resilience and works well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- High level of written and oral communication skills
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
- Knowledge of General Practice (GP) or Hospital systems
Qualifications
Essential
- Demonstrable commitment to professional and personal development
Desirable
- NVQ Level 3, Advanced level or equivalent qualifications or working towards
Personal Qualities & Attributes
Essential
- Ability to listen, empathise with people and provide person- centred support in a non-judgemental way
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from all communities
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess/manage risk when working with individuals
- Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the role e.g., when there is a mental health need requiring a qualified practitioner
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.
