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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
1. Manage caseload of CHC Fast Track patients from referral to discharge, ensuring timely coordination and person-centred planning
2. Complete comprehensive discharge assessments considering patient preferences, clinical needs, family circumstances, home suitability
3. Lead sensitive conversations with patients and families about end of life wishes, preferred place of care, discharge options
4. Build effective relationships with ICB Brokerage, care providers, community services to secure appropriate Fast Track placements
5. Coordinate multi-agency discharge planning involving ward teams, social care, housing, equipment services, family members
6. Oversee 48-hour collateral gathering, ensuring essential information captured for safe discharge decisions
7. Liaise with ward teams during board rounds for early Fast Track identification and immediate case ownership
8. Maintain accurate documentation including discharge summaries, Fast Track referrals, capacity assessments in electronic systems
9. Ensure adherence to Mental Capacity Act, Best Interest Decision-making, DOLS, safeguarding principles
10. Escalate complex cases to Band 7 Lead requiring additional clinical expertise or partnership intervention
11. Participate in quality assurance, case audits, service evaluation to support pilot objectives and business case development
12. 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 (., 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 (., care home unavailable, funding limitations)
• Support families through complex decisions (., 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
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
13. Current professional registration with relevant professional body (., NMC, HCPC, Social Work England)
14. Evidence of Continuing Professional Development undertaken since qualification
15. IT literate with competency in Microsoft Word, Excel, Outlook, and electronic patient record systems (., CareFlow)
Work Experience
Essential criteria
16. Substantial relevant post-registration experience in clinical or social care practice
17. Experience of managing complex discharges in a hospital environment
18. Relevant post-registration experience in care of patients with complex needs requiring multiagency coordination
19. Experience of patient assessment for patients with complex discharge needs
20. Ability to build relationships that support person-centred planning, involving the person in all decision-making and building on strengths and capabilities
21. Demonstrated ability to prioritise work and manage deadlines for self and others
22. Evidence of partnership working and competence in identifying and maintaining purposeful networks and collaborative arrangements
23. Experience as a competent clinical practitioner able to supervise and provide guidance to junior staff effectively
Desirable criteria
24. Community experience in discharge coordination or transfer of care services
25. Experience working within integrated discharge teams or similar multi-agency services
26. Experience of leading MDT meetings, or multi-professional care planning
Knowledge/Skills/Abilities
Essential criteria
27. Evidence of managing complex and difficult clinical situations with sound professional judgment
28. Knowledge of integrated discharge teams, Transfer of Care Hub operations, and hospital discharge processes
29. Demonstrable knowledge, understanding and application of relevant legislation (Mental Capacity Act 2005, Care Act 2014, Mental Health Act 1983)
30. Knowledge of statutory guidance and application in practice (NHS Hospital Discharge Guidance, safeguarding procedures, DOLS)
31. Experience and knowledge of timely, effective and safe discharge from an acute hospital setting
32. Specialist knowledge to advise on management of discharge processes, policies, and complex discharge scenarios
33. Knowledge of discharge pathways (P0-P3), Criteria to Reside, Discharge to Assess models, and 'Home First' principles
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.
Employer certification / accreditation badges
Applicant requirements
You must have appropriate UK professional registration.
This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.