Job responsibilities
Discharge planning
To work autonomously, managing a caseload of patients within the speciality whilst working as part of the multidisciplinary team, social services and other relevant personnel in both the hospital and community to plan and manage timely and appropriate transfers of care (discharge) for patients from the hospital.
To risk assess and identify complex discharges on admission, and in collaboration with the multidisciplinary team set discharge dates to assist the Trust in meeting NHS access targets.
To complete TOCP for pathway 3 discharges (to an interim or long-term placement), liaise with care homes and the patient and family to aid a smooth transfer of care. After patients are transferred to a care home they are also required to complete a welfare check call and identify if there were any issues with that discharge that would need an immediate response- ensuring the quality of the service.
To complete necessary assessments for nursing equipment ordering and assess patients before prescribing Hospital equipment to facilitate transfers of care. Be responsible for providing appropriate pressure relieving equipment.
Support ward based multi-disciplinary teams in making timely referrals and progressing discharge arrangements, addressing areas of concern and offering advice and practical support to enhance discharge plans.
Attend identified daily ward board reviews. Work effectively and proactively as part of the multi-professional, inter-disciplinary team.
Lead on ensuring the timely completion of key documentation to support discharge planning: advanced care plans, Fast track, Trusted Assessor documents etc.
Case manage the most complex group of patients and/or those likely to require significant integrated care in the community. Provide specialist assessment/advise on various integrated care pathways.
To lead on supporting the ward teams in developing processes to ensure all patients have a discharge plan developed by the ward within 24 hours of admission.
Provide a key point of information, reducing the duplication of communication and documenting all actions clearly within EPIC and the discharge check list.
Support and lead on the appropriate use of the Trust discharge check list.
To liaise with the Bed Managers on managing patient flow.
To ensure that accurate professional records are maintained reflecting changes in the patients discharge arrangements.
Lead on liaising with families in integrated discharge planning, ensure they are kept up to date and organising family, Best Interest and discharge planning meetings as appropriate.
Order equipment as required, liaise with families and therapists regarding delivery and track that equipment is in place for timely discharges.
Maintain clinical notes in EPIC in order that caseloads are regularly reviewed and that and delays in transfer of care are transparent to the wider organisation and external partners.
To proactively contribute to the regular discharge team caseload reviews, offering peer support and challenge to colleagues.
Support the ward MDT to ensure all patients have recorded Expected Discharge Dates recorded in Electronic Patient Record.
Monitor, record and progress all delays related to planning for discharge.
Maintain a close working relationship with social services, Clinical Commissioning Groups and care homes to assist with MDT agreed discharge plans and enable timely transfer of care.
Provide a link between the Trust and partner agencies in relation to sharing information about change and development within each organization where it may impact on discharge planning, especially in relation to commissioning and capacity. Ensuring that the ward teams are kept abreast of changes that are likely to impact on discharge pathways.
To actively involve service users in feedback of their experiences, utilising this information to develop both new and existing services.Clinical Triage
To ensure that the clinical triage notes sent with the Transfer of Care Passport to relevant providers are of a high quality and meet the standards set out in the agreed SOP.
To proactively contribute to the regular discharge team caseload reviews, offering peer support and challenge to colleagues.
Monitor, record and progress all delays related to planning for discharge.
Maintain a close working relationship with social services, integrated care boards, care homes and relevant Hubs/SPAs to enable timely transfer of care.
Provide a link between the Trust and partner agencies in relation to sharing information about change and development within each organization where it may impact on discharge planning, especially in relation to commissioning and capacity. Ensuring that the ward teams are kept abreast of changes that are likely to impact on discharge pathways.
To actively involve service users in feedback of their experiences, utilising this information to develop both new and existing services.
To work within the scope of the IFH including 7 day working and bank holidays (except 25th December).
To work collaboratively with the discharge team and the GSTT internal flow hub and be an active participant in the system wide transformation work.
Education and Training
To ensure all relevant ward staff (nursing, medical, therapy and others) have access to the policy and the key best practice standards through structured new staff induction and regular teaching, both formal and informal.
Deliver discharge related staff training/teaching, incorporating partner agency staff where appropriate with the agreement of senior staff in the relevant area.
Lead and participate in education and training programmes within the discharge team, and develop training packages as required.
To work as an effective member of the Discharge Service maintaining personal and professional development and contribute to the development of the team and its activities.
Contribute in the Trusts clinical supervision programme for staff.
Assess own educational needs and take steps to keep up to date with clinical and nursing developments in line with requirements of the Nursing & Midwifery Council/ Health and Care Professionals Council/ Social Work England.
Act as a facilitator/mentor/ Practice Educator to students and others.
To work closely with ward managers and Practice Development Teams within the area, ensuring that relevant clinical based teaching programmes are in place for all staff regarding transfer of care processes.
Lead and participate in education and training programmes within the discharge team and develop training packages as required.
Motivate, develop, support and identify training needs for department staff.
Participate in appraisals and the setting of objectives for junior staff in the department to enable them to achieve optimal effectiveness and to understand their contribution to the directorate.
Ensure that appropriate written induction programmes are available and utilised for all new staff within the department.
To lead and develop teaching programmes at Directorate and ward level to ensure best practice in accordance with Kings Discharge Policy, whilst ensuring that educational opportunities are maximised in order to develop transfer of care planning skills in others.
Research and Development
To keep up to date with research and current literature in relation to discharge, social care, Integration of health and social care.
Utilise research findings in the delivery of specialist patient care, developing new ways of working and to disseminate relevant information to staff.
Lead and contribute to audit and research within the discharge team in collaboration with colleagues, developing action plans and disseminating information.
To be aware of changes in legislation and processes, including NHS Continuing Care that may influence the outcome of transfer of care for all client groups.
Undertake regular audit cycles of data relating to the transfer of care process following which action plans must be developed and implemented with the ward staff, to address areas of concern.
To keep up to date with research and current literature in relation to discharge, social care and Integration of health & social care.
Promote and undertake research and to publish the outcome, updating own knowledge to promote excellence in clinical practice.
