This post will sit within the Discharge Team and will be based across acute hospital wards. Calderdale and Huddersfield Foundation Trust (CHFT) are implementing the Home First Model for patient care. This utilises the principles of discharge to assess which aims to ensure that patients who are medically optimised and no longer need a hospital bed, can leave hospital, and have their assessment in the most suitable setting. The discharge coordinator role is pivotal in shaping these services and asking the question “Why not home and why not today?” The successful post holder will work in partnership with CHFT, local commissioning groups, Calderdale and Kirklees Council, Locala, patients, and their carers to proactively support and facilitate timely and safe discharges from hospital to home or onward care settings. They will work directly with patients to carry out assessment and referrals for appropriate support on discharge. These assessments may include determining what support is needed at home, assessing for equipment, assessing a patient’s mobility and their ability to manage basic tasks such as getting out of bed. The post holder will communicate with patients, families, carers and associated people and co-ordinate/contribute to the safe and timely hospital discharge in partnership with other MDT/agencies. They will maintain momentum of discharge planning throughout the entire process; supporting and working collaboratively with other members of the MDT.
The post holder will undertake highly skilled support work with people who have suffered an illness or injury, resulting in temporary or permanent disability and loss of function in daily activities, This work includes managing a caseload and working independently at times.
The post holder will be working under indirect supervision of registered practitioners in the team. This will involve taking responsibility for an identified and allocated caseload following screening / assessment by a registered practitioner and will involve a degree of autonomy depending on the complexity of the assessments needed and the patient’s circumstances.
Work will be carried out in hospital or community setting and may occasionally involve visits to the patient’s own home to support arrangements for discharge. This work is a hands on, patient facing role across all settings. The post holder may be required to work weekends on a rota basis across Calderdale & Huddersfield Foundation Trust
CHFT is an integrated Trust of 6,500+ colleagues providing hospital and community services to patients and communities across Calderdale and Kirklees. We are rated as ‘Good’ by the Care Quality Commission, are a top performing Trust for Elective Recovery, Emergency and Cancer Care and widely acknowledged as a national digital lead when it comes to caring for people across our local and regional systems.
Our people are at the core of everything we do, hence our commitment to One Culture of Care. Our focus is to care for and support each other in order to provide outstanding compassionate care to our patients. That is why we are looking for an inclusive collaborative, creative, innovative and compassionate leader to join us in this role.
You will be able to demonstrate your learning to new or less experienced employees and provide training to others.
Examples of clinical duties may include:
- Participate in the review or case conference of individual patients and contribute to the evaluation and development of their discharge planning
- Support /attend the MDT and daily Board rounds to work in accordance with current CHFT discharge policies
- Identify using appropriate IT systems (Electronic Patient Records, Systm1), liaising with patients and/or carers relevant health and social care history including any existing services and which authority (Kirklees CCG, Calderdale CCG, Calderdale Council, Kirklees Council) is responsible for care provision
- Having gained informed consent from the patient and/or carer share relevant information with wider MDT to facilitate appropriate care and discharge planning
- In conjunction with the ward manager review all patients on the ward OR with the Discharge Sisters/Therapist all patients on the caseload and with the wider MDT identify those patients likely to require on-going health and social care support including care or support services.
- Ensure all those involved in the current and onward care of the patients carryout their assessments and related activities in a timely manner; this will involve negotiation with other professionals including doctors, nurses and the wider MDT to obtain medically appropriately estimated dates of discharge (EDD’s).
- Meet regularly with ward manager and the Discharge sister/Therapist to ensure clinical delays are appropriately identified ( Right to Reside ), recorded and reported in line with legislation and local policy. Check each patients plan on the Transfer of Care ( TOC ) every day and update where necessary. Ensure EPR is updated relating to any work completed
- Support the ward clerk in ensuring that transport has been arranged for the patients discharge as appropriate.
- Escalate any delays in patient pathways to the Ward Manager and or Discharge Sister/Therapist as appropriate as described in the Discharge Policy
- Prepare and co-ordinate patient information for weekly multi-disciplinary (MDT) meeting where they occur; ensure all relevant information is available and presented at the meeting.
- Work in conjunction with the MDT, support the completion of comprehensive and relevant discharge documentation
- Provide hands on assessment of needs relating to discharge and provision of low risk equipment such as walking aids, commodes, etc where this has been assessed as being required.
- Work closely with the patient’s family and friends to ensure accurate information is recorded on EPR and that they are happy and confident to provide consent to other services
- Carry out baseline assessment in relation to health and social care support, record those assessments and request simple services or alterations to packages of care for service users. Liaise with Gateway to Care and Single Point of Contact and social services directly where appropriate.
- To develop an understanding and awareness of all the resources available to meet the needs of people in the community and to contribute to the assessment of patients and/or their families/carers identifying which resource can best meet their needs
- Support the collation of any relevant statistical information which will help with developing or improving services for patients and/or carers.
- To ensure that documented information is accurate, up-to-date and reflective of the department’s involvement with individual service users and to use computerised records accordingly
This post will work over a 7 day service and therefore the post holder will be required to work weekends and bank holidays on a rota basis.
1. Formal knowledge and experience
Formal qualifications and experience expected of a new candidate (see person specification)
2. Supporting patients and service users
Supporting patients and service users and their families, and providing care throughout their care and care pathways
- Will involve assessing for, ordering, and issuing basic equipment
- Will involve discharge planning from services in conjunction with MDT and registered practitioners.
- To support / lead on onward referrals to other health related teams within CHFT /external agencies
- To undertake lone working (occasionally within a patient’s own home, which would be risk assessed prior to the visit) in line with CHFT Lone Working Policy.
- To complete administrative duties and general patient care across departments as required
- Will take part in manual and handling training and subsequently contribute to the moving and handling of patients
3. Clinical, technical and scientific roles and responsibilities
The underpinning knowledge and practice, support and interventions required of support staff to safely assist service users in meeting their optimum potential.
- Determine a treatment and/or discharge plan for an individual following a needs-based assessment, taking into account both health and social care needs.
- May require preparing and co-ordinating patient information regarding reason for admission/ referral, social history and current needs, to document this information accordingly and share with the MDT as required.
- To work as part of the wider Health and Social Care Team / PCN linking with staff from the Acute Trust, Primary and Social Care
- Carry out baseline assessment in relation to health and social care support, record those assessments and request simple services or alterations to packages of care for service users. Liaise with Gateway to Care and Single Point of Contact and social services directly where appropriate
4. Communication and information
The ability to communicate clearly, respectfully, and effectively using a range of methods – written, verbal and non-verbal. Maintaining confidentiality and protection of data and overcoming physical, sensory, cognitive and language barriers to understanding.
- Working in conjunction with the MDT, support the completion of the comprehensive and relevant discharge documentation /including onward referrals to other agencies
- At times, demonstrating good negotiation, support and conflict resolution skills where there may be disputes surrounding a plan for discharge/ treatment or assessment
- Supporting patients and relatives during stressful and emotional times
- Work closely with the patient’s family and friends to ensure accurate information is recorded on electronic systems and that they are happy and confident to provide consent to other services
- Ensuring compassionate care and excellent communication is at the forefront of all interactions and assessments
5. Safe and inclusive environments
The principles of equality, diversity and inclusion, safeguarding, protection, personal wellbeing and safety, along with the importance of duty of care and candour.
- To ensure that documented information is accurate, up-to-date and reflective of the department’s involvement with individual service users and to use computerised records accordingly
- Ensure all relevant systems are regularly reviewed and updated to ensure safe care of all patients – including safe discharge from services
- Carry out duties with due regard to the Trust’s Equal Opportunity Policy
6. Research and service improvement
Participation in research, audit, evaluation, and service improvement projects. Eg supervision, training, developments
- Attend all mandatory training and be responsible for maintaining up to date additional training and responsibilities relevant to the post (e.g. medical devices, competency training etc)
7. Leadership
The importance of being a role model, identifying areas for self improvement and supervising others, and leading on patient safety, improvements and support for others.
- Will take the responsibility for the training of others, including delivering training
8. Personal and professional values and behaviours
Understanding and demonstration of the values in the NHS Constitution and NHS People Promise, as well as self-development and personal wellbeing
- Participate in regular supervision
- Participate in an appraisal annually identifying, developing and agreeing your own development plan with your Line Manager using the Trust Appraisal
- Comply with all Trust policies, procedures and protocols
- Seek advice and support from Line Manager whenever necessary
- Maintain professional conduct including appearance at all times
- Be responsible for good time management and attendance.
- Ensuring compassionate care and excellent communication is at the forefront of all interactions and assements
