Job summary
- Provide expert clinical and operational leadership to ensure safe, timely, and effective discharge planning for patients with complex needs.
- Work collaboratively across the multidisciplinary team (MDT), community partners, and external agencies to remove barriers to patient flow and reduce delays in transfer of care.
- Act as a key point of contact and specialist advisor for all matters relating to discharge, transfer of care, and complex case coordination.
- Lead on the coordination of complex discharges, ensuring all legal, clinical, and social care considerations are addressed and documented appropriately.
- Support the delivery of the Trust's discharge improvement agenda by embedding best practice, data accuracy, and a "Home First" culture across all clinical areas.
- To ensure every patient's discharge or transfer of care is safe, timely, and person-centred, in line with Trust policies and national guidance.
- To reduce delays in discharge through proactive case management, early identification of barriers, and collaboration with relevant teams and agencies.
- To provide professional leadership and expertise in discharge planning, supporting staff across the Trust to deliver high standards of care and effective communication.
- To promote a culture of accountability and shared ownership among all clinical teams for discharge planning and patient flow.
Main duties of the job
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Proactively identify and resolve delays in diagnostics, treatment, and discharge to ensure smooth patient flow and timely transfer of care.
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Lead and coordinate the multidisciplinary team (MDT) and support services during board rounds to meet discharge and transfer KPIs.
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Take a lead role in discharge planning for patients with complex needs, liaising with families, social services, community teams, and other partners to prevent avoidable delays.
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Chair and coordinate family meetings, ensuring clear decisions, documentation, and collaborative care planning.
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Provide specialist advice and leadership to the MDT on discharge planning, funding criteria, legal frameworks, and care pathways.
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Act as a key contact for GPs, community partners, and external agencies regarding transfer of care issues and potential delays.
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Maintain accurate, timely, and compliant documentation across all Trust systems, supporting audits and performance monitoring.
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Promote early discharge and the use of the Discharge Lounge in line with the Home First and Discharge to Assess (D2A) models.
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Lead on out-of-area and privately funded discharges, ensuring safe and appropriate arrangements.
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Support staff education, mentorship, and professional development around discharge processes and best practice.
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Provide visible clinical leadership and act as a role model, advocating for patients and supporting staff in complex decision-making
About us
Ashford and St. Peters Hospitals NHS Foundation Trust serves a population of more than 410,000 people living in North-West Surrey, parts of Hounslow and beyond.
Over 3,700 highly trained doctors, nurses, midwives, therapists, healthcare scientists and other support staff make up our workforce, providing a wide range of services across our two hospital sites, Ashford, Surrey and St Peter's, Chertsey, Surrey.
We also run many specialist clinics in the community and local community hospitals and other healthcare facilities.
Our vision is to be one of the best healthcare Trusts in the country. There has never been a better time to join us in the NHS at ASPH. We are committed to providing continuous professional development and flexibility to shape our workforce around our patient care.
We are expanding our theatres at Ashford Hospital and moving towards this becoming our dedicated elective centre. We want to create a state-of-the-art centre for excellence for planned surgical procedures.
We can offer you the full range of NHS benefits/discounts and in addition:
- Excellent pension scheme and annual leave entitlement
- On-site Nurseries
- On-site staff cafes
- On-site parking
- Support in career development
- Salary Sacrifice schemes including wage stream, lease cars, Cycle to Work schemes and home electronics
Adverts may close early, so applicants are encouraged to submit an application as soon as possible.
For more information about a career at ASPH please visit:www.asph-careers.org
Job description
Job responsibilities
- To identify critical delays in the entire diagnostic, treatment and care processes and to be proactive in generating solutions that will speed up the process.
- To give direction to members of the MDT and support services (e.g. pharmacy, diagnostics) during board round to ensure achievement of transfer of care KPIs.
- To have an in-depth knowledge of all aspects of care throughout the patient journey and to communicate in an appropriate and sensitive manner highly complex information to patients, families or carers ensuring that be barriers to communication such as language difficulties, hearing impairments or cognition issues are addressed.
- To take a proactive approach to the discharge management of patients with complex needs. This will involve communicating with Family/Carers, Social Service,
- Continuing Healthcare, Community Services, GPs, Care Homes and other service providers to ensure any health or social care issues that may impact on a timely transfer of care are identified and resolved early in the patient pathway.
- To collaborate with the multidisciplinary team to identify barriers or changes to clinical conditions that may impact on the EDD or RFD and agree management plans to ensure a timely transfer of care.
- To be the point of contact for GPs and community partners for issues relating to transfers of care and identifying concerns or potential delays early.
- To arrange and undertake specialist assessments in line with Standard Operating Procedures and timescales. This will include initiating supporting assessments e.g. care diaries, behaviour diaries and ensuring the appropriate quality.
- To arrange and chair family meetings. This will include ensuring the views of patients, families/carers and the MDT are expressed and understood and clear actions and decisions are made and documented.
- To provide expertise within the MDT to develop robust discharge plans for complex patients. This will include consideration of alternative service providers or settings where clinically appropriate.
- To act as a role model at all times, as part of an integrated multidisciplinary team, ensuring high quality care is delivered to patients and their families or carers.
- To support the multidisciplinary team by providing advice on complex transfer of care planning. This will include funding criteria and eligibility, statutory responsibilities, management of challenging family meetings, best interest meetings or funding disputes and provision of information about alternative care settings.
- Utilising expert knowledge liaise with directorates and specialties about the management of patients where a delayed transfer of care is predicted or realised. This will involve proposing solutions and changes to practice to resolve the issue.
- To provide clinical and professional support and leadership to the clinical areas as appropriate.
- Utilise this holistic knowledge and expertise to assist the MDT.
- To advocate for patients at all times.
- To support the process of D2A and enabling patients to be discharged in a same day home first approach.
- To case manage complex cases on the wards supporting a multi-professional approach to discharge planning.
- To have knowledge and understanding of Power of Attorney, Court of Protection, Mental Capacity Act, Deprivation of Liberty, use of IMCA and other legal frameworks.
- In the event of a major incident [in hours] identify and support the immediate discharge and transfer of patients in order to facilitate capacity.
- To be the lead co-ordinator for family meetings in response to complex discharges to promote effective communication and resolving issues identified early.
- To support wards in highly complex and multi-professional conversations.
- Lead on Out of Area and Privately funded discharges.
Information and reporting:
- Follow the Trusts Discharge Policy and in liaison with community teams, social services, voluntary, other healthcare colleagues and providers to facilitate timely, appropriate and safe discharge of patients out of hospital to the community.
- To ensure that confidentiality of information is maintained and consent is always gained.
- To ensure that all assessments are recorded on all electronic systems currently used by The Trust using the correct response times and then stored on Trust TEAMS drive.
- To ensure that both written and electronic documentation are complete, accurate and maintained as live as is possible
- To be actively involved in the Long Length of Stay ward reviews, and attend meetings relevant to it.
- Support any audit, data review in relation to the discharge process.
- To be involved in the weekly delays sign off process with social services as required.
- To audit the effectiveness of discharge planning within the acute Trust by maintaining accurate IT records to enable collection and the analysis of data.
- To promote and ensure that the early bed release guidelines are encouraged at ward level to ensure that all suitable patients use the discharge lounge.
Education Responsibilities
- Ensure all members of the discharge team understand their role in the education of ward staff and students acting as a mentor and assessing performance as appropriate.
- In conjunction with the clinical nurse leads and educators; oversee the education of all staff within the Trust regarding discharge planning and identify learning needs and promoting competency via work based education.
- Maintain and enhance own knowledge through continuing education and training activities; identifying development needs and establish personal clinical supervision/mentorship
- With the support of the discharge Team Manager and the CPE team; support in the development and implementations of programmes for professional supervision for staff.
- Ensure that all staff are aware of when and how to report untoward incidents and how to deal effectively with patients or relatives complaints.
Job description
Job responsibilities
- To identify critical delays in the entire diagnostic, treatment and care processes and to be proactive in generating solutions that will speed up the process.
- To give direction to members of the MDT and support services (e.g. pharmacy, diagnostics) during board round to ensure achievement of transfer of care KPIs.
- To have an in-depth knowledge of all aspects of care throughout the patient journey and to communicate in an appropriate and sensitive manner highly complex information to patients, families or carers ensuring that be barriers to communication such as language difficulties, hearing impairments or cognition issues are addressed.
- To take a proactive approach to the discharge management of patients with complex needs. This will involve communicating with Family/Carers, Social Service,
- Continuing Healthcare, Community Services, GPs, Care Homes and other service providers to ensure any health or social care issues that may impact on a timely transfer of care are identified and resolved early in the patient pathway.
- To collaborate with the multidisciplinary team to identify barriers or changes to clinical conditions that may impact on the EDD or RFD and agree management plans to ensure a timely transfer of care.
- To be the point of contact for GPs and community partners for issues relating to transfers of care and identifying concerns or potential delays early.
- To arrange and undertake specialist assessments in line with Standard Operating Procedures and timescales. This will include initiating supporting assessments e.g. care diaries, behaviour diaries and ensuring the appropriate quality.
- To arrange and chair family meetings. This will include ensuring the views of patients, families/carers and the MDT are expressed and understood and clear actions and decisions are made and documented.
- To provide expertise within the MDT to develop robust discharge plans for complex patients. This will include consideration of alternative service providers or settings where clinically appropriate.
- To act as a role model at all times, as part of an integrated multidisciplinary team, ensuring high quality care is delivered to patients and their families or carers.
- To support the multidisciplinary team by providing advice on complex transfer of care planning. This will include funding criteria and eligibility, statutory responsibilities, management of challenging family meetings, best interest meetings or funding disputes and provision of information about alternative care settings.
- Utilising expert knowledge liaise with directorates and specialties about the management of patients where a delayed transfer of care is predicted or realised. This will involve proposing solutions and changes to practice to resolve the issue.
- To provide clinical and professional support and leadership to the clinical areas as appropriate.
- Utilise this holistic knowledge and expertise to assist the MDT.
- To advocate for patients at all times.
- To support the process of D2A and enabling patients to be discharged in a same day home first approach.
- To case manage complex cases on the wards supporting a multi-professional approach to discharge planning.
- To have knowledge and understanding of Power of Attorney, Court of Protection, Mental Capacity Act, Deprivation of Liberty, use of IMCA and other legal frameworks.
- In the event of a major incident [in hours] identify and support the immediate discharge and transfer of patients in order to facilitate capacity.
- To be the lead co-ordinator for family meetings in response to complex discharges to promote effective communication and resolving issues identified early.
- To support wards in highly complex and multi-professional conversations.
- Lead on Out of Area and Privately funded discharges.
Information and reporting:
- Follow the Trusts Discharge Policy and in liaison with community teams, social services, voluntary, other healthcare colleagues and providers to facilitate timely, appropriate and safe discharge of patients out of hospital to the community.
- To ensure that confidentiality of information is maintained and consent is always gained.
- To ensure that all assessments are recorded on all electronic systems currently used by The Trust using the correct response times and then stored on Trust TEAMS drive.
- To ensure that both written and electronic documentation are complete, accurate and maintained as live as is possible
- To be actively involved in the Long Length of Stay ward reviews, and attend meetings relevant to it.
- Support any audit, data review in relation to the discharge process.
- To be involved in the weekly delays sign off process with social services as required.
- To audit the effectiveness of discharge planning within the acute Trust by maintaining accurate IT records to enable collection and the analysis of data.
- To promote and ensure that the early bed release guidelines are encouraged at ward level to ensure that all suitable patients use the discharge lounge.
Education Responsibilities
- Ensure all members of the discharge team understand their role in the education of ward staff and students acting as a mentor and assessing performance as appropriate.
- In conjunction with the clinical nurse leads and educators; oversee the education of all staff within the Trust regarding discharge planning and identify learning needs and promoting competency via work based education.
- Maintain and enhance own knowledge through continuing education and training activities; identifying development needs and establish personal clinical supervision/mentorship
- With the support of the discharge Team Manager and the CPE team; support in the development and implementations of programmes for professional supervision for staff.
- Ensure that all staff are aware of when and how to report untoward incidents and how to deal effectively with patients or relatives complaints.
Person Specification
Qualifications
Essential
- Registered Nurse
- Mentorship/teaching qualification or equivalent experience
Desirable
- Degree of relevant areas or evidence of recent study
Experience
Essential
- Relevant experience at a senior Staff Nurse level
- Multi-disciplinary working and ability to provide the lead in interdisciplinary decision making
- Manage Conflict
Desirable
- Working within an MDT environment and experience on leading complex discharges
- Knowledge of the types of funding available for patients entering residential or nursing care
Knowledge
Essential
- Comprehensive knowledge of issues related to discharge planning
- Knowledge of the NHS framework and guidance on Discharge Planning
- Experience and/or knowledge of Discharge to Assess
Person Specification
Qualifications
Essential
- Registered Nurse
- Mentorship/teaching qualification or equivalent experience
Desirable
- Degree of relevant areas or evidence of recent study
Experience
Essential
- Relevant experience at a senior Staff Nurse level
- Multi-disciplinary working and ability to provide the lead in interdisciplinary decision making
- Manage Conflict
Desirable
- Working within an MDT environment and experience on leading complex discharges
- Knowledge of the types of funding available for patients entering residential or nursing care
Knowledge
Essential
- Comprehensive knowledge of issues related to discharge planning
- Knowledge of the NHS framework and guidance on Discharge Planning
- Experience and/or knowledge of Discharge to Assess
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
