The post holder will work as an experienced clinician as a key member of the Flow and Discharge Team based within the acute inpatient services (working age adult and Older peoples). The post holder will work collaboratively with the Patient Flow Hub, Senior Flow and Discharge Coordinators (SF&DC), inpatient wards (internal and external), crisis teams, relevant community teams / services, service users and their families, working in a targeted way to achieve the best pathway for inpatients on discharge with early identification of factors that would potentially delay timely discharge and impact on provision of appropriate aftercare. The post holder will focus mainly on patients facing homelessness as barrier to discharge across all three boroughs. To sit organisationally within the Patient Flow services and be present on the inpatient wards working with an identified caseload to enable effective discharge planning for patients facing homelessness. The postholder would be required to travel to other Trust sites to support the discharge planning process for patients where required.
- To provide supervision as required for team members in accordance with Trust supervision standards
- Identify and minimise delays to discharge and support patients discharge to the community or back to Trust inpatient units.
- Provide regular, informative, and accurate bed management information
- Improve satisfaction of service users and carers in discharge planning arrangements and transfer arrangements from Oxleas wards and out of borough/ private placements.
- To work closely with the inpatient wards and Home Treatment Teams and be a key contact for discharge coordination.
- Attend and participate in the Clinically Ready for Discharge (CRFD) and Length of stay (LOS) meetings.
- Attend and participate in ward rounds, including Section 117 meetings
Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children’s centres, schools and people’s homes.
We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary’s Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.
Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:
We’re Kind
We’re Fair
We Listen
We Care
- To work and support the Flow and Discharge Team under the management of the Flow and Discharge Team Lead and Clinical Nurse Manager.
- To develop strong working relationships and work in close partnership with ward multi-disciplinary teams, Patient Flow Hub, SF&DCs,Crisis teams, Community teams / services and social services to facilitate discharge from acute in-patient care to prevent delays and resolving complex discharge arrangements, for the effective, efficient and optimum management of inpatient beds.
- To ensure early assessment of barriers to discharge and proactively support and facilitate timely and safe discharge from hospital to home or onward care settings.
- To work with individuals identified on admission, in daily huddle meetings, ward rounds and Delayed Transfers of care meetings to ensure a complete picture of the acute care pathway and patient flow and any barriers to discharge.
- To support and co-ordinate timely and appropriate assessment and safe discharge of people from acute inpatient beds.
- Through effective clinical leadership, assertive care co-ordination and management of health and social care resources, ensure that pro-active, clinically effective, and efficient acute care pathways are implemented to Greenwich, Bromley and Bexley residents admitted to acute in-patient wards.
- Work in partnership with the management team, business manager, IT and finance departments.
3. Key Tasks and Responsibilities
- To provide supervision as required for team members in accordance with Trust supervision standards
- Identify and minimise delays to discharge and support patients discharge to the community or back to Trust inpatient units.
- Provide regular, informative, and accurate bed management information
- Improve satisfaction of service users and carers in discharge planning arrangements and transfer arrangements from Oxleas wards and out of borough/ private placements.
- To work closely with the inpatient wards and Home Treatment Teams and be a key contact for discharge coordination.
- Attend and participate in the Clinically Ready for Discharge (CRFD) and Length of stay (LOS) meetings.
- Attend and participate in ward rounds, including Section 117 meetings
Core Job Objectives and Tasks:
1. Implement and resolve discharge-planning arrangements to avoid delayed discharged and ensure safe discharge planning and follow up.
- As a core member of the inpatient service, lead in working in close partnership with local services and colleagues to resolve discharge delays by:
o Assertive facilitation and troubleshooting of complex discharge planning arrangements.
o Identify potential discharge delays within 72 hours of admission and agree action plans in relevant meetings.
o Attend daily Borough based patient flow huddles to provide feedback on progress in discharge facilitation.
o Implement safe and effective clinical practice including delivering evidence-based interventions throughout the acute care pathway ensuring an integrated multi-disciplinary and whole service system approach to the implementation of discharge plans.
o To develop effective relationships with housing providers, tenancy support teams and benefit agencies specific to the Borough.
o To verify the purpose of admission and expected length of stay for all new admissions to acute inpatient wards and ensure that there is an identified Expected Date of Discharge (EDD) and identify likely pathway out of hospital as the earliest opportunity.
o Investigate cases that are about to pass / have passed projected milestone / discharge dates in the acute care pathway ie. discharge review, discharge plan in place, discharge date.
o Support carer engagement and work closely with carers and relatives in the interests of supporting timely discharge.
o Ensuring clear, concise discharge plans are swiftly communicated in writing and verbally (where necessary) to appropriate people, including service user and carer, community keyworker, RC / AC, and GP (other involved agencies i.e. supported accommodation provider, day service)
2. Establish and maintain effective, agreed bed management information and infra-structures by:
- Working in close partnership with the patient flow team, inpatient services, IT department and business manager to set up appropriate systems.
- Enter and disseminate appropriate data requirements, maintaining up to date, accurate and relevant information management systems including:
o Weekly maintenance and dissemination of data relating to delayed discharge and length of stay in partnership with the business office and IT department.
o Establish and maintain active data base/ information systems in liaison with IT Department providing delayed discharge data.
3. Work effectively and professionally as an experienced clinician with colleagues across Directorate, Trust, Local Authority and other directorate services
- Participate pro-actively and regularly in team meetings, establishing productive and supportive relationships within the Discharge coordination team.
- Establish and maintain professional and effective partnership relationships with colleagues in: Oxleas House, Green Parks House and Woodlands Unit, locality services, other Oxleas NHS Foundation Trust services e.g. forensic services and other providers.
- Implement agreed service objectives and standards
- Implement agreed policies and procedures
- Work in accordance with professional codes of conduct
4. In partnership with senior multi-disciplinary staff in the service, deliver an integrated quality system to include:
- Contributing to meeting requirements and priorities within Clinical Governance framework.
- Implement evidence-based practice
- Facilitate the effective and meaningful involvement of service users and carers in all aspects of the discharge facilitation process, including individual care planning and review.
- When required participate and support in the investigation of complaints and incidents.
5. Implement effective partnership working, liaison and communication
- Promote effective liaison, communication and partnership working with locality services/ CMHTs, acute wards and other core service partners including Local Authorities, housing departments, Primary Care and probation services, day service providers, addiction services and local ethnic minority communities.
- Represent the service at forums and meetings as appropriate and agreed with the Flow and Discharge Team Lead.
- Contribute to the delivery and promotion of a joint agency and multi-professional service culture.
- Ensure that the service promotes and works within a multi-cultural and non-discriminatory framework.
6. Undertake personal development including:
- Proactive participation in Professional and management supervision by the allocated SF&DC, annual objective setting and PDR/appraisal
- Pro-actively participate and identify training and development opportunities
- Ensure up to date knowledge of mental health care including evidence-based interventions, national/local policy and service developments
