Detailed job description
and main responsibilities
To act as the discharge “key worker” to co-ordinate and facilitate safe and timely discharges
Working in partnership with the MDT and other care services for making sure that all parties are aware of changes.
Communicates effectively with a range of people about day to day tasks as required within limits of job role and training.
Ensure all documentation applicable for the role is recorded accurately, legibly, signed and JOB DESCRIPTION dated in accordance with trust policies and procedures.
Work with MDT to ensure holistic care for patients and their representatives
Main responsibilities
To work closely with the clinical inpatient care groups and discharge team highlighting patients with complex needs specifically those patients who are deemed to be have No Criteria to reside in an acute hospital bed where supported intervention is required to progress the discharge plan.
· Ensure all inpatients have a discharge plan commenced on admission, an expected date of discharge in line with the no criteria to reside (no C2R) guidance, the SAFER Care Bundle and manage discharge dependent actions to reduce any potential delays.
· To work in partnership with the ward MDT, the system SPA (Single Point of Access team) Cluster teams, social services, community care providers, integrated care boards and the discharge team and voluntary agencies regarding simple and complex needs identified during the admission process to provide effective discharge planning to patients and their representatives that facilitates timely discharge.
Facilitate and coordinate discharge plans at appropriate meetings including daily handovers, MDT meetings, care reviews and / or case conferences to agree and finalise discharge plans with patients and next of kin.
Update the daily the discharge database and escalate any issues delaying discharge
Person specification
Experience
Essential criteria
1. Discharge key worker experience
Key worker
Essential criteria
2. NVQ level 3: health / social care management or equivalent Good standard of general education Care Certificate
3. Experience of working in a hospital setting
4. Understanding of complex discharge planning in care of the elderly, stroke, long term conditions and vulnerable adults.
5. Experience of supporting service users specialised care needs to enable informed decision making
6. Good Communication Skills Problem solving skills Team working qualities including understanding the needs of other professions.
7. Able to speak English as necessary to undertake the role
Desirable criteria
8. Previous experience of working with patients requiring CHC and Social Services involvement.
9. Experience of patient flow and discharge planning
10. Use of IT clinical systems ie: e-CaMis, Health of the ward, discharge databases
11. Knowledge of Integrated Care Systems