Job overview
Supported Transfer of Care (STC)
We are transforming the way we support individuals stepping down from secondary care mental health services to Primary Care. The STC Practitioner will play a critical role in this transformation by providing visible clinical and professional leadership, leading on the coordination of safe supported discharge and transition into community-based holistic care, and shaping service development alongside partners.
This model supports people for up to 12 months post-discharge, using a named worker approach, with strong emphasis on:
·Holistic and preventative support
·Physical health and wellbeing
·Meaningful social connection
·Recovery-focused, person centred care
·Strategic community-engagement and relationships
This is a unique opportunity for experienced mental health professionals to lead, influence and shape a new model of care that places community, autonomy and recovery at its core.
Main duties of the job
Key Aims of the Role:
·Provide senior clinical leadership and role-model evidence-based practice across the pathway
·Provide clinical leadership and hold a caseload of service users stepped down from CRT/CIMHS
·Deliver time limited (up to 12 months), person-centred interventions that support long term recovery and integration into community and primary care systems.
·Investment and Partnership - Build strong, sustainable relationships with Primary Care, VCSE partners, community organisations, and local residents.
·Embed the STC pathway within the local neighbourhood model, ensuring collaboration across the Integrated Neighbourhood Teams (INTs).
·Provide mental health clinical leadership for emerging Neighborhood teams in Newham, and support effective interface between these structures and CRT/CIMHS aligned teams.
·Address social determinants of health, promote recovery, and reduce dependency on secondary care services.
·Understand the needs and strengths of the local community, create culturally sensitive spaces and understand people in the context of their lives
·Champion a culture of accountability, inclusivity and high standards, ensuring practice reflects the voices of service users and carers
Working for our organisation
Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive – so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.
Detailed job description and main responsibilities
Please see job description in documents
1. To promote and offer a range of clinical and non-clinical interventions within CIMHS / Primary Care.
2. To provide assessment and care planning expertise relevant to your profession
3. To lead on the development of a new care pathway between Primary Care, CIMHS and CRT.
4. To provide effective signposting to a range of health, social, voluntary sector and community-based resources and services.
5. To work with service users to: support shared decision-making about self-management; provide brief psychological interventions, where qualified to do so and where appropriate;
6. To, where possible, operate without the need for formal referral from GPs, including accepting some direct bookings where appropriate.
7. The role will not directly line manage staff in CIMHS/CRT, but will offer support, training, supervision and matrix management of staff who are operating an STC Model or caseload where necessary. Acting as a professional lead for the Pathway
8. To support the CIMHS, CRT and GP workforce on this new pathway. Including the delivery of any relevant training and induction.
9. To attend relevant meetings and work collaboratively with colleagues to enhance patient care and co-produce the new care pathway.
10. Engage service users and stakeholders throughout the development of the model.
Person specification
Education and training
Essential criteria
11. Registered Professional in either Nursing (Mental Health), Social Work or Occupational Therapy, with current registration with NMC, Social Work England or HCPC.
12. Evidence of post registration continued professional development, qualifications or equivalent experience
Experience
Essential criteria
13. Experience practicing as a Mental Health professional in the Community
14. Previous experience of functioning as a team member
15. Previous experience of Management and Clinical Supervision, including annual appraisal
16. Previous experience of service development, quality improvement and of bringing innovation and new ideas to practice
17. Previous experience of working within the health or care system
Desirable criteria
18. Lived-experience of accessing mental health services
19. Experience of using DIALOG+ (as a service user or professional)
Knowledge and skills
Essential criteria
20. Sound knowledge of the applicable professional body code of practice
21. Good knowledge and training of adult safeguarding
22. Good knowledge of current and relevant local and national agendas impacting Community Mental Health, including the Community Mental Health Framework for Adults and Older Adults
23. Sound knowledge and understanding of the Mental Health Act and Care Act, relevant national standards and other relevant national policies.
24. Excellent knowledge & understanding of recovery principles
25. Knowledge of quality improvement metrics and tools including relevant audits to
26. Excellent communications skills
27. Skills in using electronic clinical systems and associated Microsoft 365 applications
Desirable criteria
28. Knowledge of NICE guidance in relation to a wide range of mental disorders and the ability to ensure that evidence based practice with clear clinical outcomes is embedded into practice.