Overview
To assess medically optimised patients who are referred to the Intermediate Care Service (ICS) and require support to discharge from the hospital setting. Liais e with members of the multidisciplinary team, patients and their relatives to ascertain patient needs and identify requirements to facilitate a safe and timely discharge. Identify the appropriate discharge pathway in line with national guidance. Coordinate all assessments required before discharge and ensure all equipment is in place for discharge. Promote a home first ethos and least restrictive option when identifying the discharge pathway for a patient. Ensure clear concise communication with acute colleagues, external partners, patients and their families to support safe, timely discharges from the acute setting. Support the ICS to deliver same day assessments of medically optimised patients referred to the service, thereby supporting patient flow within the acute hospital setting. Address issues that would cause delays in discharge and escalate as required. Identify or report safeguarding concerns that would affect a patient’s discharge plan and liaise with the appropriate colleagues to ensure these are addressed.
Responsibilities
* To work as part of the Intermediate Care Service (ICS) contributing towards effective, safe, timely discharges of patients from the acute setting who require care support for discharge.
* To manage a complex caseload of patients with responsibility for their discharge planning to ensure discharges are expedited in a timely and safe manner.
* To promote the ICS ethos of home first when discharge planning.
* Effectively manage discharge planning for medically optimised patients requiring support on discharge, taking action to ensure delays are promptly addressed by the relevant ward or department.
* Work closely with members of the multi-disciplinary team (MDT) when discharge planning.
* To take appropriate action to ensure effective discharge planning is undertaken in line with national discharge pathways.
* To monitor delayed discharges and take immediate action, including escalation of issues to ICS Managers as required.
* Liaise with external agencies and colleagues to progress timely, safe discharges.
* Deal with complex information including co-ordinating difficult discharges or transfers from the acute setting, ensure senior team members are aware and escalate any issues causing delays.
* Provide a wide range of information and advice about services available in the community to support a patient and their families following discharge.
* Engage with patients and their carers while completing required assessments and planning discharge plans.
* Ensure records of discussions, actions and interventions are accurately recorded in the relevant places and on the relevant systems, both health and social, in line with good practice.
* Support effective patient flow and patient experience by providing clear communication.
Communication
* Support and advise other staff on health and social care processes and resources available to them to assist in timely discharges and appropriately challenge colleagues as required.
* Work effectively as a member of the team, supporting senior colleagues to implement agreed discharge plans.
* Ensure all communication, which may be complex, contentious or sensitive, is undertaken in a responsive and inclusive manner, focusing on improvement and moving forward.
* Ensure all communication is presented appropriately to different recipients, according to levels of understanding and potential barriers such as language, culture, or health conditions.
* Be able to deal with challenging conversations and signpost to relevant services for patients and families.
Data Management
* To input and extract data from health and social care information systems to maintain accurate records and enable required activity related to patient records, face-to-face activity and support service provision regarding discharge arrangements.
* Proactively enhance knowledge regarding new services/resources and changes in local and national policy that may impact discharge planning for specific patient cohorts.
Quality Initiatives
* Accept responsibility for maintaining a high quality of service to patients by continual development and adapting own work as agreed.
* Contribute to improving services and ways of working under the direction of ICS managers, providing clear feedback on policies and strategies and their impact on services provided to patient cohorts.
* Contribute to the development of robust discharge plans and associated documentation, and provide clear information about support services and care pathways as appropriate.
* Act in a manner that upholds the values of the Trust and the profession, contributing to clinical governance.
* Adhere to and maintain evidence of following trust and professional policies, procedures and quality approaches, encouraging others to do the same.
* Work within the limits of own competence and area of responsibility, proactively seeking help and advice when needed.
* Act as a discharge expert to enhance knowledge in relation to discharge planning and pathways available.
* Prioritise own workload and manage time effectively to meet priorities without compromising quality.
* Monitor quality of work in own area and alert others to quality issues, reporting any errors to the appropriate person.
Service Development and Improvement
* Promote and maintain good customer care.
* Work within policies and procedures to achieve team objectives with appropriate autonomy subject to timescales, budget or other constraints.
This advert closes on Tuesday 4 Nov 2025
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