Care Home Pathway Coordinator will be based at Croydon University Hospital (CUH) and will coordinate all aspects of supported discharges and the single point of discharge from CUH to care homes. The role will focus on improving patient flow, reducing delayed transfers of care (DTOC) and avoiding unnecessary readmissions, LOS reduction and 4‑hour breach for care home residents.
Responsibilities
* Identify care home residents requiring discharge planning, ensuring up‑to‑date discharge summaries, Universal Care Plan (UCP) and medication reviews.
* Collaborate with discharge teams and multidisciplinary teams to finalise all discharge documents prior to patient discharge.
* Ensure hospital teams have relevant information to assess and provide appropriate treatment plan and that on discharge, care homes receive the information to enable continuity of care.
* Escalate complex and challenging cases to Senior Discharge Coordinators for support or advice.
* Ensure smooth and timely communication between the Trust and partner agencies involved in patient discharge/transfer of care to avoid unnecessary delays.
* Review, complete and action the Red Bag Checklist for patients admitted and discharged, ensuring the Red Bag remains with the resident while in the hospital and returns with all relevant documentation, medication (if required) and personal items.
* Track usage of Red Bags and eRedBags by care homes and support the process of the Red Bag Scheme in the hospital and SWL ICB including the eRedBag process.
* Provide nursing discharge letters and work with the pharmacy team to provide “To Take Out” (TTOs) on discharge of the resident.
* Ensure the Hospital Transfer information is part of the assessment process for care home residents on arrival to the hospital.
* Ensure the hospital team informs the care homes of the discharge process within 48 hours.
* Track missing Red Bags within the hospital, liaise with care homes to return any missing Red Bags and support distribution of new, found or replacement Red Bags to care homes where needed.
* Work with hospital staff to ensure all stages of the Hospital Transfer pathway are completed to enable tracking and evaluation of the scheme.
* Promote and raise awareness of the Hospital Transfer Pathway, its use, benefits and impact across the hospital; create resources and provide training to support this to hospital staff.
* Act as a point of contact for all Red Bag matters within the hospital and provide advice, guidance and support to staff, family members and patients where needed.
* Facilitate safe and timely discharge of patients who are medically fit for discharge and ensure care home residents settle back into the care home to reduce LOS and DTOC.
* Ensure compliance with correct IG and data protection policies.
* Ensure completion of all stages of the hospital element of the Hospital Transfer and Discharge Pathways for care homes.
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