An exciting opportunity has arisen for an experienced, motivated and compassionate Band 6 Registered Nurse to join our Integrated Discharge Team.
This is a rewarding role for an individual who is passionate about ensuring patients receive safe, timely and person-centred discharges. Working closely with the multidisciplinary team, you will coordinate complex discharge planning, facilitate patient flow and support patients to transition safely from hospital to their preferred place of care.
A key aspect of this role is leading on Continuing Healthcare (CHC) funded discharges. You will be responsible for completing Decision Support Tools (DSTs), undertaking comprehensive assessments, liaising with Integrated Care Boards (ICBs), community providers, families and care agencies to ensure timely access to appropriate packages of care.
The successful applicant will demonstrate excellent communication, clinical assessment, leadership and organisational skills, with the ability to manage competing priorities within a fast-paced acute environment.
Experience in oncology and discharge are desirable however not required as we are here to help you develop in the role.
The post holder will:
- Coordinate and facilitate complex patient discharges across multiple inpatient wards.
- Lead the assessment and coordination of NHS Continuing Healthcare (CHC) funded discharges.
- Work collaboratively with Integrated Care Boards (ICBs), community nursing teams, social workers, hospices and external agencies.
- Ensure patients are discharged safely, appropriately and without unnecessary delay.
- Identify and proactively address barriers to discharge.
- Participate in multidisciplinary team meetings and discharge planning discussions.
- Provide expert advice and support to ward teams regarding discharge pathways and Continuing Healthcare eligibility.
- Escalate complex discharge issues where appropriate.
- Maintain accurate electronic patient records and documentation.
- Support achievement of Trust discharge performance standards and patient flow objectives.
- Act as an advocate for patients and their families throughout the discharge process.
- Contribute to service improvement projects and audits relating to discharge planning.
The Christie is one of Europe’s leading cancer centres, treating over 60,000 patients a year. We are based in Manchester and serve a population of 3.2 million across Greater Manchester & Cheshire, but as a national specialist around 15% patients are referred to us from other parts of the country.
We provide radiotherapy through one of the largest radiotherapy departments in the world; chemotherapy on site and through 14 other hospitals; highly specialist surgery for complex and rare cancer; and a wide range of support and diagnostic services. We are also an international leader in research, with world first breakthroughs for over 100 years.
We run one of the largest early clinical trial units in Europe with over 300 trials every year. Cancer research in Manchester, most of which is undertaken on the Christie site, has been officially ranked the best in the UK.
Clinical
Prioritise patients referred to the service who are in their last days of life.
To provide a robust, timely and comprehensive assessment of patients care needs in preparation for their discharge/transfer of care. This should be a holistic assessment including their carer’s needs/commitments and the active part they can play in supporting the patient once home.
To be responsible for a delegated patient caseload and provide proactive case management to ensure a quality patient experience on discharge from the Trust.
To develop an individual discharge care plan for patients in collaboration with health, social services, community services, the patient, carer and family in order to facilitate a safe/co-ordinated transfer of their care management to the community services.
To re-evaluate patients and carers needs throughout the discharge process and adjust plans accordingly
To act as an advocate and support for patients/carers/relatives to improve their experience of discharge or transfer from the Trust into the community or alternative healthcare setting.
To empower patients and their representatives to engage fully in the above processes
To organise capacity assessments, best interest meetings and case conferences in relation to patients included in my case load. Include the patient, family members, carers, and hospital and community personnel as appropriate.
To directly order or facilitate the ordering of any community equipment that may be required to ensure a safe transfer of care takes place.
With patients consent, forward written information to community personnel in line with Trust guidelines and the Data Protection Act
Liaise closely with Trust and community colleagues when arranging patient’s safe discharge or transfer. This may include Consultants, General Practitioners, Social Workers, Specialist Nurses, District Nurses, CCG’s, Commissioners and staff at other healthcare settings.
To increase awareness within the Trust multi-disciplinary team of the role of colleagues in the community services and inform them of any relevant community care legislation affecting the care planning of the patient on discharge
Maintain accurate and comprehensive documentation and patient records, either written or IT based, in line with both Trust policy and NMC guidelines
To provide specialist support and advice pertaining to discharge planning at the daily ward board rounds, ward multi-disciplinary meetings and Trust staff members.
Participate in the protection of vulnerable adults, reporting any serious untoward incidents to the Trust Safeguarding Lead and participate in any meetings/actions relating to my case managed patients.
Communication
To use advanced communication skills to provide emotional and psychological support when working with patients and carers in sensitive situations, when breaking bad news, discussing end of life issues or dealing with difficult/challenging situations.
Ensure good communication with patients, their carers, nursing and medical colleagues, other healthcare and social care professionals and community services
To supply written information to patient, their family, relatives, and carers in regard to the community services that will be involved in their ongoing care following their discharge.
Maintain own advanced communication skills through attending formalised teaching sessions or courses
To report and record incidents/accidents that occur during the discharge/transfer process in accordance with Trust procedure
Additional Services
Community Oxygen Provision
The team advises Trust registered staff regarding the Department of Health process to follow when ordering home oxygen for patients.
Liaise with the Oxygen Provision and Installation service, the patient’s General Practitioner and Regional Respiratory Teams as agreed with the Trust and Northwest Regional Oxygen Lead and complete any necessary documentation.
Provide advice and training of Trust staff on request and via the Trust website.
To facilitate the use and recall of hospital equipment loaned out to facilitate a timely discharge.
National Standard Framework for NHS Funded Nursing Care and NHS Continuing Healthcare (CHC)
To carry out all the Trust screening of identified inpatients in compliance with the
NSF for NHS Funded Nursing Care and NHS Continuing Healthcare
Lead on the application for Fast Track CHC funding that can be used to facilitate the rapid discharge of a patient who is entering the last days of life.
Complete a CHC checklist to identify if a patient is eligible for a full process application to be made for funding via CHC funding.
Involve/inform the service user, family members, and carers of the process that is to be carried out, outline their involvement/entitlements, and gain their consent for data sharing with other professionals.
If a full process application is identified act as the Trust Co-ordinator of the required case conference. Collate all the required documentation and arrange the attendance of all the relevant staff members, patient, and carers at the case conference.
A regional CHC member will chair the meeting and present the patient’s case at the next Commissioners meeting where a decision re-funding will be made If NHS funded Continuing Health Care is to be applied for act as the Co-ordinator for the process.
Management
To be responsible for organising and planning own caseload to meet service and patient priorities, including the re-adjustment of plans as situations change/arise.
To provide statistical information on clinical activity required by the hospital and external bodies, including the Department of Health and NHS Continuing Healthcare teams.
Represent the Discharge Team Leader, in their absence, at any designated meetings or in relation to any discharge or service enquiries, should they occur.
Participate in planning the development of the service to meet the increasing demands and complexity of cases.
To provide management support for junior staff and act as a mentor to designated staff.
To organise daily work schedule ensuring appropriate and effective deployment of staff for appropriate patient needs.
Be aware of Health & Safety issues and ensure relevant risk assessments are undertaken.
Ensure all trust policies and procedures are adhered to and new ones implemented as necessary.
Regularly liaise and report to the Discharge Team Manager on team affairs and developments.
Assist in team recruitment process when required.
Take a progressive approach to the management of short and long-term sickness/absence in collaboration with Discharge Team Manager.
Education and Training
To act as part of a highly specialised resource team for staff within the hospital and for community teams.
Lead and advise in the training and education of all staff in all aspects of Discharge Planning.
To take responsibility for maintaining own essential training and professional development.
Demonstrates the agreed set of values and be accountable for own behaviour.
