Hospital Discharge Care Co-ordinator
This job is now closed
Care Co-ordinator roles are new to Primary Care and we are looking to recruit a Hospital Discharge Care Co-ordinators within the Tame Valley Primary Care Network (PCN).
This role will involve working with patients with a range of presentations and also their families and carers.
The care co-ordinator will be integral in overseeing the interdisciplinary care and will be responsible for co-ordinating a package of care and support from a variety of specialists who may be working with the patient.
Main duties of the job
The Care Co-ordinator will support all key activity across the PCN; supporting the PCN manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.
The Care Co-ordinator will ensuring all relevant services, acute, community, primary care, social care, housing and voluntary, are linked in order to co-ordinate care and support for patients during and following discharge and to prevent re-admissions.
Viaduct Care is the GP Federation and is a partnership of all GP practices across Stockport.
The federation was formed to empower local GPs to provide the best possible care for patients whilst tackling some of the challenges faced by General Practice by helping doctors and other healthcare professionals work together, share resources and expertise.
Our vision is to be consistently recognised for enabling the delivery of high quality patient centred healthcare, which is innovative, equitable, efficient, effective and contributing to a healthy population in Stockport.
Whatever stage you’re at in your career, we’ll provide you with the high-quality support you need to continue developing your skills, achieve job satisfaction and help shape the future of healthcare to make a real difference to people’s lives.
Main Roles & Responsibilities:
· Responsible for developing timely and person-centred ‘step-down’ or ‘step-up’ plans for patients based on the principle of ‘no place like home’.
· Understand the discharge home pathways, communicating with a clear and consistent focus on ‘discharge to assess’ (D2A) and ‘home first’.
· Support safe discharges of people on pathways 1 to 3 through close working with secondary care, quality assurance of information and practical support.
· Communicate with Hospital discharge teams improving commitment from all partners to the D2A and home first.
· Contact patients following a hospital discharge and assess their short and long-term needs and link the patient to appropriate support to aid their recovery.
· Ensure the person and any carers, family or friends are involved in and informed about what is happening and when.
· Identify and remove blockages and, where necessary, change processes to improve patient discharge requirements.
· Ensure clear patient recovery plans are created.
· Closely monitor and document progress against the recovery and support plan.
· Ensure adjustments are made to the support provided as required and in a timely way and the support is ended when it is no longer needed.
· After a sufficient period of recover, where it appears a person may need support on a long-term basis, liaise with appropriate professionals to ensure timely assessment, for example a Care Act (2014) assessment or NHS continuing health care assessment (or both).
· Arrange necessary primary care follow-ups with GPs and Practice Nurses
It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.