Job Description

We are seeking a dynamic and experienced Clinical Liaison Practitioner to join our Transfer of Care Hub team, supporting the Guildford and Waverley Discharge to Assess (D2A) programme.



This Band 7 role is hosted by Royal Surrey NHS Foundation Trust and employed by Surrey Heartlands ICB. You will play a pivotal role in coordinating NHS Continuing Healthcare (CHC) Fast Track and D2A pathways, ensuring patients are discharged safely and efficiently, with assessments carried out in the community wherever possible.

Please note:

this post is only open to staff from Royal Surrey NHS Foundation Trust and its system partners (Ashford and St Peters NHS Foundation Trust, Surrey

Heartlands ICB, and Surrey County Council). Applicants from outside of these organisations will not be considered.

Reasons to apply:

This role provides an opportunity to be at the forefront of an innovative model of integrated care. This role allows you to make use of your skills and experience to work across acute and community settings to support some of the most vulnerable patients. You'll be part of a supportive team driving innovation and best practice in discharge planning and CHC processes.

You will be responsible for actively contributing to and supporting the discharge process as it relates to, NHS funded Discharge to Assess (D2A) pathway, and NHS Continuing Healthcare (CHC) Fast Track (FT) process, for clients requiring CHC assessment, as well as other patients requiring or already eligible for NHS CHC funding.



You will lead on supporting discharges from the acute hospitals providing an in-reach approach.



You will actively support the shared agenda of avoiding CHC assessment in hospitals, and planning for most CHC assessments in community, after discharge from hospital, in line with national and local policies and strategic directions.



Key relationships will be with Ward staff and the Discharge Team at The Royal Surrey County Hospital, to ensure that patients within the acute are swiftly identified and considered for the D2A NHS funding or NHS CHC Fast track funding. The postholder will be working with the Transfer of Care Hub, RSCH discharge team, ward staff and the social care practitioners to identify suitable patients for the CHC led Discharge to Assess pathway and CHC Fast Track, ensuring that referrals are progressed in a timely manner and submitted to the relevant CHC services. The aim of role is to prevent delays in discharge from hospital.



Royal Surrey is a compassionate and collaborative acute and community Trust. Recognising that our 5000 colleagues are our greatest strength, we offer a comprehensive health and wellbeing program along with a commitment to developing and advancing your career. Our diverse and welcoming Royal Surrey family will ensure you that you feel valued from your initial interview through your entire tenure.



We are clinically led and provide joined up care by bridging the gap between hospital and community services alongside regional specialist cancer care. Our main acute hospital site is in Guildford with community hospital sites at Milford, Haslemere and Cranleigh. We provide adult community health services in homes across Guildford and Waverley.



The Care Quality Commission (CQC) have given us an overall rating of Outstanding.



Royal Surrey has a strong reputation and history to build on. We are proud of our achievements and we are investing in our colleagues through our commitment to supporting professional development as well as investing more than 45 million in our physical environment and new equipment in the next few years. There has never been a better time to join us.



Although it isn't the Trusts normal practice, adverts may close early, so you are encouraged to submit an application as soon as possible.



A video about the Royal Surrey - https://www.youtube.com/watch?v=R96pMboIYdo



You will need to ensure that robust / lean protocols for assessment and discharge of patients are established and followed, in cooperation with the Acute hospital's discharge team and with the relevant CHC services, namely CHC led D2A, and the CHC Fast Track team. The post holder will understand the care needs of the patients, to support the timely provision of appropriate services, to meet the care needs identified. This includes ensuring assessments and active participation in the CHC led D2A and Fast Track process ensuring patients are discharged in a timely manner once they meet their discharge ready date to prevent delays, and CHC assessments are undertaken outside of hospital.



You will be involved in training and supporting hospital and/or community staff in completing CHC led D2A and CHC Fast Track referrals and assessments to a competent level to enable robust mechanism for continuation of swift discharges when the post-holder is not on site.

This role involves linking and collaborating with patients and families/carers, and other health and social care providers in primary, secondary, independent, and voluntary care, to promote communication, provide information with regards the CHC D2A and assessment process, ensure seamless care and support for patients and their carers.



Very occasionally in special circumstances, and after authorised by the line manager, the post holder will undertake CHC assessments for NHS Continuing Healthcare, Checklist for patients in hospital.



You will work closely with the CHC Clinical Liaison Practitioner (CLP) and the CHC Case Manager/Nurse Assessor who will carry out care package reviews, CHC Checklists, FT reviews, and DSTs for patients discharged from hospital in community.



The job description and person specification are an outline of the tasks, responsibilities and outcomes required of the role. The job holder will carry out any other duties as may reasonably be required by their line manager within the Transfer of Care Hub and the CHC Senior Leadership Team.



This role is expected to evolve and progress, as the needs of the service and overall, the NHS are changing. The post holder will act as a key link between the hospital, Transfer of Care Hub and the Surrey Heartlands ICB/Continuing Healthcare Service.



The job description and person specification may be reviewed on an ongoing basis in accordance with the changing needs of the Department and the Organisation.