Overview
The post holder will demonstrate expert knowledge in discharge options and services available, whilst providing support to the patient, their family/carer and care workers in communicating the possible plan, estimated date of discharge and managing expectations and any concerns raised. The post holder will aim for a safe and sustainable discharge by highlighting and managing any potential risks thus reducing the risk of readmission.
The purpose of the role is to contribute at the multidisciplinary team meeting by ensuring that the patient's wishes are heard, needs are assessed and are well managed to achieve a timely discharge. Also, to promote advanced care planning where appropriate to avoid unnecessary hospital admissions.
To identify social care needs of older people and to be aware of / able to access adult social care processes which facilitate the provision of care on discharge from hospital.
To act as a link between the wards and community teams/services for discharge planning.
The identification, assessment, planning, implementing and evaluating care as a practitioner with specialist Discharge Planning Skills. This involves the completion of specialist discharge planning liaising with the discharge planning nurse to complete specialist nursing assessments.
This role is to work closely with healthcare professionals, clinicians, social work teams, family members, personal care services and other multi-disciplinary team members to deliver a high quality, patient focused service
Cambridgeshire and Peterborough NHS Foundation Trust is a health and social care organisation dedicated to providing high-quality care with compassion to improve the health and wellbeing of the people we care for, as well as supporting and empowering them to lead a fulfilling life.
Our clinical teams deliver many NHS services, not only via inpatient and primary care settings, but also within the community. These services include children's, adult and older people's mental health, forensic and specialist mental health, learning disabilities, primary care and liaison psychiatry, substance misuse, social care, research and development.
Responsibilities
1. Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act.
2. Any data that is taken/shared as part of a phone call or transported, or transferred electronically must be undertaken with regard to CPFT information Governance and information Security policies.
3. The post holder must adhere to CPFT risk assessment and risk management processes.
4. The post holder must adhere to infection control policies and procedures.
5. Undertake mandatory training and any other training relevant to the role as required by Cambridgeshire & Peterborough NHS Foundation Trust (CPFT).
6. The post holder must participate in clinical and other audits as required.
7. Provide patients and their families/carers with information on standards they should expect from the team.
8. Provide discharge planning training programmes and oversee issues across the Trusts to ensure all professional needs are met, thus ensuring the Trust's discharge policies are adhered to.
9. Create discharge education packages appropriate to different grades/disciplines across different settings.
10. Identify, monitor, investigate and record reasons for delayed discharges and review ways of working with multi-disciplinary teams in order to reduce these delays.
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