Job Description

To assess medically optimised patients who are referred to the Intermediate Care Service (ICS) who will require support to discharge from the hospital setting.

Liaising with members of the multidisciplinary team, patients and their relatives to ascertain patient needs and identify requirements to facilitate a safe and timely discharge. Identifying the appropriate discharge pathway, in line with National guidance.

Coordinate all assessments required before discharge and ensure all equipment is in place for discharge.

Promote a home first ethos and least restrictive option when identifying the discharge pathway for a patient.

Ensuring clear concise communication with acute colleagues, external partners, patients and their families, to support safe, timely discharges of patients from the acute setting.

Support the Intermediate Care Service to deliver same day assessments of medically optimised patients that are referred to the service, therefore supporting patient flow within the acute hospital setting.

To resolve any issues that would cause a delay in a patients discharge and escalate as required

Identify or report any safeguarding's that would affect a patients discharge plan and liaise with the appropriate colleagues to ensure these are addressed



PLEASE NOTE, WE MAY CLOSE THIS VACANCY EARLY IF WE RECEIVE HIGH NUMBERS OF APPLICATIONS.



To work as part of the Intermediate Care Service (ICS) contributing towards effective, safe, timely discharges of patients from the acute setting who require care support for discharge



To manage a complex case load of patients with responsibility for their discharge planning to ensure discharges are expedited in a timely and safe manner.



To promote the ICS ethos of home first when discharge planning



Effectively manage discharge planning for medically optimised patients requiring support on discharge, taking action to ensure delays are promptly addressed by the relevant ward or department.



Work closely with members of the multi-disciplinary team (MDT) when discharge planning



To take appropriate action to ensure effective discharge planning is undertaken in line with national discharge pathways



To monitor delayed discharges and take immediate action, including escalation of issues to ICS Managers as required



Liaise with external agencies and colleagues to progress timely, safe discharges



Walsall Healthcare NHS Trust is an integrated Trust and the only provider of NHS acute care in Walsall, serving a population of 284,300. It provides inpatient and outpatient services at the Manor Hospital as well as a wide range of services in the community. Walsall Manor houses the full range of district general hospital services under one roof. The 170 million development was completed in 2010, and ongoing upgrades ensure the Trust now has state-of-the-art facilities, including a Critical Care Unit, Neonatal Unit, Obstetric Theatre, and Integrated Assessment Unit. A new Urgent and Emergency Care Centre, opened in March 2023, has significantly improved emergency care facilities and capacity, providing almost 5,000 square metres of additional clinical space.



Communication

Deal with complex information including co-ordinating difficult discharges or transfers from the acute setting, ensure senior team members are aware and escalate any issues causing delays Effectively provide a wide range of information and advice about services available in the community to support a patient and their families following discharge To be able to effectively engage with patients and their carers whilst completing required assessments and planning discharge plans. To ensure records of discussions, actions and interventions are accurately and clearly recorded in the relevant places and on the relevant systems, both health and social, in line with good practice. To support effective improved patient flow and patient experience by providing clear communication Support and advise other staff on health and social care processes and resources available to them, to assist in timely discharges and appropriately challenge colleagues as required. Work effectively as a member of the team, supporting senior colleagues to implement agreed discharge plans. Ensure all communication, which may be complex, contentious or sensitive, is undertaken in a responsive and inclusive manner, focusing on improvement and ways to move forward. Ensure all communication is presented appropriately to the different recipients, according to levels of understanding, type of communication being imparted and possible barriers such as language, culture, understanding or physical or mental health conditions. Be able to deal with challenging conversations and situations with patients' and their families and be able to signpost to relevant services.

Data Management

To input and extract data from health and social care information systems to maintain accurate records and allow required activity with regards to patient records, face to face activity and support service provision regarding discharge arrangements. Proactively enhance own knowledge base regarding new services / resources, changes in local and national health and social care policy practice, which may impact on discharge planning for specific cohorts of patients.

Quality Initiatives

Accept responsibility for ensuring the maintenance of a high quality of service to patients by continual development and adapting own work and takes on new tasks as agreed. Under the direction of ICS managers and others, contribute to improving services and ways of working, providing clear feedback on polices and strategies and their impact on services provided to patient cohort. Contribute to the development of robust discharge plans and associated documentation, the provision of clear information about support services available and care pathways available as appropriate. Post holders will act in a manner that upholds the values of the Trust and that of the profession ensuring the service delivered contributes to supporting the principles of clinical governance. Adhere to and maintain evidence of following trust and professional policies and procedures and other quality approaches as required. Encouraging others to do the same. Work within the limits of own competence and area of responsibility and accountability. Proactively seeks help and advice where needed. Act as a discharge expert in order to enhance personal, team and patient knowledge in relation to discharge planning and the various discharge pathways available. Prioritises own workload and manages own time effectively to ensure priorities are met and quality is not compromised. Proactively monitors the quality of work in own area and alerts others to quality issues, reporting any errors or issues to the appropriate person.

Service Development and Improvement

Promote and maintain good customer care. * Work within policies and procedures to achieve agreed team objectives and is given freedom to do this autonomously subject to timescales, budget or other constraints as appropriate.