Pathway Facilitator

Job description

Job responsibilities

Professional/Clinical

1. To facilitate admission and discharge of patients ensuring high quality holistic and individualised care to patients and their families.

2. To ensure patient-centred and clinically effective service.

3. To participate in developing joint action plans, protocols and pathways and influence the use of these.

4. To work in line with protocols and pathways with appropriate information which prioritise palliative care patients and address the particular needs of this vulnerable group of patients.

5. Work closely with Trust colleagues in continuing care to design appropriate packages of care.

6. To facilitate patients being discharged into a virtual bed.

7. Work with the multidisciplinary team in order to provide a patient focused service ensuring smooth planning, co-ordination and communication between primary, intermediate and secondary services in order to facilitate seamless care.

8. To work in partnership with the referrals/triage team, medical, nursing, social worker and allied health professionals..

To be aware of local arrangements for health and social care, intermediate, primary care and community services. (It is increasingly evident that effective hospital discharges can only be achieved when there is good joint working between the NHS, local authorities, housing organisations, primary care and the independent and voluntary sectors).

Undertake assessments of patients and carers, identifying their psychological, social, practical and spiritual needs in accordance with NICE guidelines, demonstrating and applying knowledge of the options for discharge in order to develop a discharge plan to meet their needs.

. To start planning the patient's discharge within 24 hours of the patient's admission using the discharge tool within the integrated notes.

1To ensure individuals and their carers are actively engaged in the planning and delivery of their care.

1To liaise with ward staff, pharmacy regarding organisation of TTOs.

1To attend daily MDT handovers and Central Referral meetings as required.

. To be responsible for making follow-up calls within 24 hours after discharge to patients and their families as necessary documenting the outcome in the notes.

. To escort patients in transfers of care as necessary.

Ensure open, honest and effective communications are maintained in order to facilitate joint working practices around integrated patient pathways for transfer or care.

To work in conjunction with all agencies to provide the appropriate equipment for discharge.

To liaise with the Ward Manager on all day-to-day issues re admission/discharge within the SPC in-patient unit.

To demonstrate skills to maintain, encourage and enhance effective communication between all agencies.

To actively listen and communicate appropriately in difficult and complex situations.

To maintain clinical competencies and work within the ward team as directed.

To deliver high quality, compassionate and effective care.

To ensure the administration of drugs and therapeutic substances are given in accordance with legal and NMC requirements.

Management Responsibilities

1. Understands SPC philosophy/operational policy/service specification.

2. To promote and enhance collaborative working through the use of reflective practice.

3. To take remedial action to diffuse complaints and potential complaints from patients and/or their relatives/carers thus maintaining good relationships between the service and service users.

Education

1. To maintain personal development fulfilling all requirements of PREP and the organisation.

2. To update and develop own clinical/theoretical knowledge relating to the specialty and other areas of nursing to ensure care is innovative, research based and of a high standard.

Audit, Research & Development

1. To critically analyse the relevance of appropriate research related to practice and allow this to influence and alter own practice as appropriate.

2. Is critically aware of the range of research approaches that can be used to develop knowledge from practice.

3. To review causes of delays in discharge, liaise with relevant staff within and outside the hospital, patients, relatives and carers.

4. To participate in audits and research pertinent to admissions/discharge planning.

To record accurate statistical data and information

Read the attached job description and person specification file for more information.

Person Specification

Qualifications

Essential

• Registered Nurse Level1 - Current registration.

Desirable

• Teaching and assessing course.
• Working towards Degree.

Experience

Essential

• Experience of working within a multidisciplinary team.
• Experience of working with patients with multiple pathologies and developing and delivering care plans designed to meet their needs.
• Experience in arranging packages of care to facilitate discharge

Desirable

• Experience in Continuing Health Care Assessments.
• Experience of resource management.
• Experience of audit research.

Skills, Abilities and Knowledge

Essential

• Ability to maintain and improve standards of care.
• Up to date knowledge of current clinical/professional issues.
• Knowledge of evidence-based practice.
• Understanding of resource management.
• Knowledge and understanding of multi professional and agency working

Communication

Essential

• oExcellent verbal, written and interpersonal communication skills.
• oBasic computer skills

Personal and People Development

Essential

• oSelf-awareness.
• oPositive approach to work to meet patient service needs.
• oEnthusiasm/motivation.

Personal Attributes / Behaviours

Essential

• oAble to identify with the Trust's commitment to safeguarding and promoting the welfare of children and young people/vulnerable adults.

Other

Essential

• oAble to communicate effectively in written and verbal English Language

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

Norfolk Community Health and Care NHS Trust

Address

Priscilla Bacon Lodge

Century Place, Colney

Norwich

NR4 7YA

Employer's website

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