The Integrated Transfer of Care (ITOC) Team is a dynamic and multi-skilled team consisting of nurses, occupational therapists, physiotherapists, and Assistant Practitioners. We also work in alignment with the recovery hub and private sector nursing and residential homes.
Our purpose is to support a safe and timely hospital discharge of people who are medically fit, and no longer need hospital care, to a place more suitable to the person's needs. Assessments and care provision can then be tailored to support people to regain strengths and skills so that they can live as independently as possible. We also aim to avoid admission for patients in A&E and Frailty departments who require intervention to allow them to be discharged home.
Responsibilities:
The main priority of the team is to consider home first with ongoing community interventions, if required. The band 5 physiotherapist will working alongside the band 6 team members to support with physiotherapy for the ITOC patients.
The ITOC model aims to support better outcomes for people leaving hospital by:
Reducing the time people spend in hospital when they no longer need acute care preventing hospital acquired infections and 'deconditioning' (the loss of strength and independence)
Assessing people in a more appropriate environment than the hospital giving a more accurate indication of their strengths and needs
Providing multidisciplinary reablement and rehabilitation plans, and if necessary short-term care and support, to help people gain and re-gain independence, preventing or reducing need for longer term care.
The model also enables the urgent care system to prioritise acute hospital care for those people who need it.
The ITOC teamwork in partnership with individuals and families to identify their own needs and short-term goals, recognising that person-centred care planning and intervention is key to the person accomplishing the outcomes they want to achieve.
There are two teams within the service: The Hospital Discharge Team identify people who have onward care needs and then make necessary arrangements for discharge to one of the two pathways; Home First and Bedded Pathway.
Home First is the default pathway for people leaving hospital and should be the first consideration for everyone. The team will work with the individual and determine if support is required to return home and arrange the necessary support for discharge.
Where people are unable to go home immediately, they will be discharged to the Bedded Pathway. This means they will be placed in the recovery hub or occasionally in a residential or nursing care home where they will be assessed by a member of the multidisciplinary team. The team will work with the person to identify the type of care, support or rehabilitation they need to meet the outcomes they want to achieve including, wherever possible, a return home.
Longer term needs will be assessed following a period of in the recovery. Both sides of the team come together to cover A&E and Frailty patients across Kirklees.
Locala is committed to helping employees achieve a positive work- life balance and promotes mobile working. Staff are provided with mobile technology.
There will also be opportunities to broaden your scope of practice through supporting across the wider service of Unplanned and Intermediate Care.
To find out more about Locala see our 'Thrive Strategy'
We reserve the right to close the vacancy earlier than the stated date should we receive sufficient applications.
About us
Here at Locala we are part of the community and have often cared for generations within the same family and continue to be part of the NHS family also delivering care under the same ethos.
Locala Health and Wellbeing embraces diversity and inclusion and encourages applicants from people from all backgrounds with our ambition to have a workforce that represents the wider communities we live and work within, which you can support us to achieve.
We are an organisation that celebrates and values the individuality of our colleagues lived experiences and can adapt accordingly, recognising the value inclusivity brings when delivering equitable, high quality healthcare to our local communities. Where everyone feels valued, has the ability to develop, has flexible working opportunities, with a sense of belonging, supported by our Inclusivity Groups.
"Locala is a 'Disability Confident' employer and as such any disabled applicants who meets all the essential criteria are guaranteed to be invited to the assessment process."
Just a few of the benefits you can enjoy:-
Flexible working
- We are committed to supporting our colleagues to have a good work-life balance and welcome conversations about flexible working wherever possible.
Generous pension
- We offer a generous, defined contribution, pension scheme with matched contribution + 2% up to a maximum of 8%
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Refer a Friend Scheme -
If you know a friend or family member who works at Locala on a substantive contract, you may be able to take advantage of our Refer a Friend Scheme. You both could receive a reward of 500 each, after you have successfully started your role with us.
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