Discharge Liaison Nurse SEU

Job description

Job responsibilities

Job Summary:

The post holder aims to facilitate effective, efficient and timely discharge of patients from SEU at the John Radcliffe Hospital. Particular emphasis is placed upon complex multi-disciplinary assessments including patients with complex health and social care, palliative care or rehabilitation needs.

Job Purpose:

To work towards a culture of reducing the number of avoidable admissions and delays once patients no longer meet the criteria to reside, in partnership with primary and secondary care, community and social services and voluntary organisations.

To work across professional boundaries, maintaining positive communication links between community and secondary care staff, social services, private and voluntary sector workers and allied health professions to promote collaborative working.

To ensure that patients have an up to date discharge plan commenced on admission, which is patient centered and carried out in a timely manner, taking actions to reduce any potential delays.

Provide advice to all partners with a key relationship and patients/carers/relatives on progressing safe and appropriate discharge and the services available to support this

To promote an ethos of admission avoidance through use of ambulatory pathways.

To be involved in developing and maintaining discharge documentation and audits.

To provide education and support to ward staff in clinical settings on current legislation, discharge planning, and NICE guidance.

To design, develop and deliver appropriate training packages.

To be involved in the collection and presentation of data for those patients who are medically optimised for discharge or with an extended length of stay

To co-manage the Discharge Coordinators

Key responsibilities:

• To take the lead role in ensuring that patients are safely discharged from hospital

• Provide expertise, advice and support to ward and care home staff. To ensure that staff gain and maintain appropriate skills and competencies to manage simple and complex discharge needs on a daily basis, and to reduce delay.
• To identify patients whose discharge is delayed and inform relevant system partners of the most urgent in priority order, to positively influence funding decisions, and by use of specialist nursing knowledge, challenging inappropriate decisions.
• If delays occur, identify causative factors and seek solutions to them in partnership with clinical teams.
• Attend relevant meetings with system partners
• To convene and chair multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
• To work with ward staff to ensure patients have up to date, realistic discharge plans and take action either personally or through delegation to implement, monitor and amend the plans if necessary in partnership with all relevant personnel.
• To ensure ward staff refer appropriate patients, in a timely manner, to the Transfer of Care Hub
• Lead and advise in the training and education of all staff in all aspects of Discharge Planning and further relevant developments either in a group setting or on an individual basis
• Co-manage discharge coordinators to ensure they are efficient and effective in their role
• Liaise with the Single Point of Access, Short Stay Hub Beds, and Community Hospitals to ensure that available beds are used as effectively as possible
• Maintain accurate and comprehensive documentation and patient records either written or IT based in line with both Trust policy and NMC guidelines.
• Work collaboratively with the Health and Social Care Economy to appropriately place patients
• To initiate and design clinical audits of discharge planning and act on findings making recommendations on change to hospital discharge practice

• To adhere at all times to trust policies for the protection of vulnerable adults
• To act as advocate and support for patients/carers/relatives to improve their experience and discharge from hospital
• To be aware of both national & local issues related to Discharge Planning- NICE Guidance, Continuing NHS Funded Care, Care Act 2014, Mental Capacity Act 2005 and the National Discharge Policy
• Represent the Trust in health and social care discussions relating to patient transfer / discharge processes, forging links with external agencies to improve practice.
• To maintain and update the Trusts Discharges Intranet Site
• Implement and uphold the Oxfordshire Protocol of Choice
• Maintain a Ready List of inpatients detailing their discharge plan

Communication & Working Relationships

Ensure good communication with patients, their carers, nursing and medical colleagues, Social Services and other statutory and voluntary organisations.

To provide support, help and advice to families, relatives / carers through the provision of appropriate information

To report and record incidents/accidents in accordance with Trust Policy.

Maintain confidentiality of information consistent with legislation.

Maintain legible and comprehensive records.

Create opportunity for people to communicate effectively.

PERSONAL AND PROFESSIONAL DEVELOPMENT

The post-holder will be required to keep himself/herself fully up-to-date with their relevant area of practice. They must ensure all statutory and mandatory training is undertaken as per Trust Policy. They are expected to identify their own personal training needs that will facilitate development within the role. They must act at all times in adherence with the NMC code of conduct and the policies and protocols of the Oxford University Hospitals NHS Foundation Trust. Professional or study leave will be granted at the discretion of the Trust, in line with the prevailing Terms and Conditions of Service, to support appropriate study, postgraduate training activities, relevant courses and other appropriate personal development needs.

MANAGEMENT

The post-holder will be required to work within the Trust's management policies and procedures, both statutory and internal, accepting that the resources available to the Trust are finite and that all changes in clinical practice or workload, or developments requiring additional resources must have prior agreement with the Trust. He/she will undertake the administrative duties associated with the care of his/her patients.

INFORMATION GOVERNANCE

All staff must complete annual information governance training. If you have a Trust email account this can be completed on-line, otherwise you must attend a classroom session. For further details, go to the Information Governance intranet site.

DATA QUALITY

Data quality is a vital element of every member of staffs job role. The Oxford Radcliffe Hospitals recognises the importance of information in the provision of patient care and in reporting on its performance. Data quality is therefore crucial in ensuring complete, timely and accurate information is available in support of patient care, clinical governance, performance management, service planning, and financial and resource planning and performance.

All staff should ensure that they have read and understood the Trusts Data Quality Policy

This job description is intended as a guide to the duties and responsibilities of the post and should not be regarded as a complete list of those required to be fulfilled under the written statement of the main terms and conditions of employment. The contents may be amended from time to time subject to developing service needs, although such amendment would occur following appropriate consultation with the post holder

Person Specification

Qualifications and experience

Essential

• Educated to degree level
• Experience in MDT working
• Senior nursing experience

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.

Certificate of Sponsorship

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).

Employer details

Employer name

Oxford University Hospitals NHS Foundation Trust

Address

John Radcliffe Hospital

Headley Way, Headington

Oxford

OX3 9DU

Employer's website

https://www.ouh.nhs.uk/ (Opens in a new tab)