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Job Overview
Join a pioneering new End of Life Discharge Team and use your clinical expertise to transform discharge experiences for patients at life's most precious moment. This is a 6-month internal secondment opportunity to work exclusively with CHC Fast Track patients, managing the discharge process from assessment through to safe transfer home.
As our End of Life Discharge Case Manager, you will be at the heart of our specialist team, working closely with patients, families, and multi-agency partners to ensure dignified, timely discharges that honour patient choice. You'll manage a caseload of CHC Fast Track patients, complete comprehensive assessments, lead sensitive conversations about end of life preferences, and coordinate with ICB Brokerage, care providers, and community services.
This role sits within the Palliative Care specialty and reports to the Band 7 End of Life Discharge Lead. The team will manage approximately 12 new referrals per week with an estimated caseload of 40-60 patients. This is an opportunity to develop specialist skills in end of life care whilst making a genuine difference to patients and families during the most important time.
Main duties of the job
Manage caseload of CHC Fast Track patients from referral to discharge, ensuring timely coordination and person-centred planning
Complete comprehensive discharge assessments considering patient preferences, clinical needs, family circumstances, home suitability
Lead sensitive conversations with patients and families about end of life wishes, preferred place of care, discharge options
Build effective relationships with ICB Brokerage, care providers, community services to secure appropriate Fast Track placements
Coordinate multi-agency discharge planning involving ward teams, social care, housing, equipment services, family members
Oversee 48-hour collateral gathering, ensuring essential information captured for safe discharge decisions
Liaise with ward teams during board rounds for early Fast Track identification and immediate case ownership
Maintain accurate documentation including discharge summaries, Fast Track referrals, capacity assessments in electronic systems
Ensure adherence to Mental Capacity Act, Best Interest Decision-making, DOLS, safeguarding principles
Escalate complex cases to Band 7 Lead requiring additional clinical expertise or partnership intervention
Participate in quality assurance, case audits, service evaluation to support pilot objectives and business case development
Work collaboratively within specialist team, share learning, maintain professional resilience through emotionally demanding work
Working for our organisation
NBT Cares. It's a very simple statement; one which epitomises how everybody across our organisation goes the extra mile to ensure our patients get the best possible care.
NBT Cares is also an acronym, standing for caring, ambitious, respectful and supportive – our organisational values.
And our NBT Cares values are underpinned by our positive behaviours framework – a framework that provides clear guidance on how colleagues can work with one another in a constructive and supportive way.
Detailed Job Description And Main Responsibilities
This role offers a unique opportunity to develop specialist skills in end of life discharge coordination whilst working within a supportive, dedicated team. You'll have access to expert clinical advice from the Palliative Care Team, comprehensive training in CHC Fast Track processes, and regular supervision to support you with the emotional demands of the work.
Key Responsibilities
Clinical Assessment & Planning:
Identify Fast Track patients through board rounds, referrals from Palliative Care Team, or direct ward requests
Conduct initial assessment to confirm Fast Track eligibility (rapidly deteriorating condition meeting criteria)
Complete comprehensive Fast Track assessment documentation including clinical information, functional ability, and care needs
Assess capacity and ensure appropriate Mental Capacity Act processes are followed
Identify any safeguarding concerns and make appropriate referrals
Determine appropriate discharge destination based on patient preference, clinical needs, and available resources
Develop discharge plans that are realistic, achievable, and person-centred
Coordination & Problem-Solving
Gather collateral information within 48-hour timeframes (therapy assessments, equipment needs, social circumstances)
Coordinate with multiple agencies simultaneously to expedite discharge processes
Troubleshoot barriers to discharge and identify solutions (e.g., equipment delays, funding issues, placement challenges)
Escalate complex cases to Band 7 Lead when clinical, ethical, or practical challenges arise
Manage competing priorities and changing situations in a fast-paced hospital environment
Respond to changes in patient condition that affect discharge planning (deterioration, death, change of preference)
Sensitive Conversations & Family Support
Discuss prognosis, dying process, and end of life preferences with patients who have capacity
Support families to understand their loved one's deteriorating condition and likely timescales
Facilitate conversations about preferred place of care and realistic options available
Manage family expectations when preferences cannot be met (e.g., care home unavailable, funding limitations)
Support families through complex decisions (e.g., nursing home vs home with package, hospice admission)
Provide emotional support whilst maintaining professional boundaries
Signpost to bereavement services, chaplaincy, or other support as appropriate
Demonstrate cultural sensitivity and adapt communication style to individual needs
Partnership & Multi-Agency Working
Submit Fast Track referrals to ICB Brokerage with complete, accurate information
Follow up referrals promptly and chase progress when delays occur
Build relationships with care home managers and home care providers to facilitate quick placements
Coordinate with Palliative Care CNS for symptom management advice and clinical support
Work with hospice admission teams (St Peter's, Weston) when hospice care is appropriate
Liaise with community teams to ensure seamless handover and continuity of care
Share discharge information using standardised community contact sheets
Documentation & Information Governance
Complete Fast Track assessment forms accurately and comprehensively
Document all conversations, decisions, and actions in electronic patient records
Maintain Transfer of Care Documents to high standards
Ensure information sharing complies with information governance and patient confidentiality
Complete legal documentation accurately (Lasting Power of Attorney checks, Mental Capacity Assessments, Best Interest Decisions)
Provide clear, professional handover information to community colleagues
Quality & Professional Development
Participate in service evaluation and data collection for the pilot
Contribute to development of processes, documentation standards, and training materials
Engage in regular clinical supervision and reflective practice
Identify own learning needs and undertake training as required
Maintain professional registration and meet CPD requirements
Act as a role model for compassionate, patient-centred care
Working Arrangements
Core hours Monday to Friday 08:00-17:00
Weekend working on a rotational basis to maintain case continuity for Fast Track patients
Flexibility to attend family meetings or coordinate urgent discharges outside core hours when needed
Based in Transfer of Care Hub with close links to Palliative Care Team
What We Offer
Specialist training in CHC Fast Track processes and national frameworks
End of life care training delivered in partnership with Palliative Care Team
Skills development in sensitive conversations and grief support
Regular clinical supervision with focus on emotional wellbeing
Opportunity to contribute to service development and evaluation
Supportive team environment that recognises the emotional demands of the work
Clear potential for permanent establishment if pilot demonstrates impact
Support & Wellbeing
The Trust recognises that working with dying patients and bereaved families is emotionally demanding. You will receive regular clinical supervision, have access to wellbeing support services, and work within a team culture that encourages reflective practice and mutual support. Self-care and emotional resilience are essential for this role.
Person specification
Education/Training/Qualifications
Essential criteria
Current professional registration with relevant professional body (e.g., NMC, HCPC, Social Work England)
Evidence of Continuing Professional Development undertaken since qualification
IT literate with competency in Microsoft Word, Excel, Outlook, and electronic patient record systems (e.g., CareFlow)
Work Experience
Essential criteria
Substantial relevant post-registration experience in clinical or social care practice
Experience of managing complex discharges in a hospital environment
Relevant post-registration experience in care of patients with complex needs requiring multiagency coordination
Experience of patient assessment for patients with complex discharge needs
Ability to build relationships that support person-centred planning, involving the person in all decision-making and building on strengths and capabilities
Demonstrated ability to prioritise work and manage deadlines for self and others
Evidence of partnership working and competence in identifying and maintaining purposeful networks and collaborative arrangements
Experience as a competent clinical practitioner able to supervise and provide guidance to junior staff effectively
Desirable criteria
Community experience in discharge coordination or transfer of care services
Experience working within integrated discharge teams or similar multi-agency services
Experience of leading MDT meetings, or multi-professional care planning
Knowledge/Skills/Abilities
Essential criteria
Evidence of managing complex and difficult clinical situations with sound professional judgment
Knowledge of integrated discharge teams, Transfer of Care Hub operations, and hospital discharge processes
Demonstrable knowledge, understanding and application of relevant legislation (Mental Capacity Act 2005, Care Act 2014, Mental Health Act 1983)
Knowledge of statutory guidance and application in practice (NHS Hospital Discharge Guidance, safeguarding procedures, DOLS)
Experience and knowledge of timely, effective and safe discharge from an acute hospital setting
Specialist knowledge to advise on management of discharge processes, policies, and complex discharge scenarios
Knowledge of discharge pathways (P0-P3), Criteria to Reside, Discharge to Assess models, and 'Home First' principles
If you apply for this vacancy and have not received a communication from North Bristol NHS Trust within three weeks of the closing date, please assume that on this occasion your application has been unsuccessful.
Please note that North Bristol NHS Trust does not reimburse travel expenses relating to interview attendance.
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North Bristol NHS Trust are committed to safeguarding and promoting the welfare of children and young people and expects all staff and volunteers to share this commitment.
The successful applicant(s) will normally commence at the minimum of the scale unless they have previous NHS service at the same band. Progression through the scale is by annual increments.
At North Bristol Trust (NBT), we know diverse and inclusive environments lead to happier and healthier teams and improved patient care and outcomes. We are committed to equality of opportunity, to being fair and inclusive, and to being a place where we all belong. We therefore particularly encourage applications from candidates who are currently underrepresented in NBT's workforce at Band 8a and above. These include people from Black, Asian and minority ethnic backgrounds, disabled people and LGBTQIA+ people.
Please note that stringent pre-employment checks are undertaken on all successful applicants prior to commencement in post.