Job summary
- Main area
- Aging and Health
- Grade
- Band 6
- Contract
- Permanent
- Hours
- Full time - 37.5 hours per week
- Job ref
- 384-SB-EMF16736
- Employer
- Royal Surrey NHS Foundation Trust
- Employer type
- NHS
- Site
- Royal Surrey County Hospital
- Town
- Guildford
- Salary
- £37,162 - £44,629 Per annum (pro rata) inc HCAS
- Salary period
- Yearly
- Closing
- 05/08/2024 23:59
- Interview date
- 14/08/2024
Employer heading
Case Manager - Band 6
Band 6
Job overview
JOB PURPOSE
The focus of the Complex Discharge Service is to support the timely identification, assessment and support for discharge to the most vulnerable patients in the Royal Surrey. The Complex Discharge Service supports the identification and planning of complex discharge in addition to ensuring patients are transferred to the most appropriate care setting in a timely manner whilst providing a safe, effective and positive patient experience. The principle responsibilities of this team are:
Ø To provide clinical expertise and decision-making for timely effective discharge and the management of patients admitted from care home.
Ø To provide clinical expertise and decision-making for timely effective discharge and the management of patients referred to the Complex Discharge Service
Ø Work with the Team Lead and provide support the Complex Discharge Coordinators, providing guidance and oversight to ensure high standards of care and service delivery.
Ø Conduct and oversee mental capacity assessments to determine patients' ability to make informed decisions about their care.
Ø Make and support best interest decisions for patients who lack capacity, ensuring their needs and preferences are prioritised.
Ø Act as the primary point of contact between the hospital, care providers, and community services to ensure coordinated and continuous care.
Main duties of the job
JOB SUMMARY:
Ø To work with the team lead to prioritise and allocate workload on a daily basis, liaising with other teams as required to identify new patients admitted or referrals.
Ø To assess all newly admitted patients within allocated workload to devise a Transfer of Care management plan. This will involve understanding the patient’s current condition and previous level of functioning. Information will be obtained from families/carers. GP’s, Community Providers, Social Care and other relevant providers to identify and address issues early that may impact on a timely transfer of care.
Ø To have an in-depth knowledge of all aspects of care and discharge pathways and utilise a holistic knowledge and expertise to assist in leading the MDT to support timely discharge.
Ø To ensure the patient and family are informed on admission about the transfer of care process and agree and negotiate how they will be involved throughout the patient journey.
Ø To be the point of contact for patients/families, care homes and carers for issues relating to transfers of care and identifying concerns or potential complaints early.
Working for our organisation
Royal Surrey is a compassionate and collaborative acute and community Trust. Recognising that our 5000 colleagues are our greatest strength, we offer a comprehensive health and wellbeing program along with a commitment to developing and advancing your career. Our diverse and welcoming Royal Surrey family will ensure you that you feel valued from your initial interview through your entire tenure.
We are clinically led and provide joined up care by bridging the gap between hospital and community services alongside regional specialist cancer care. Our main acute hospital site is in Guildford with community hospital sites at Milford, Haslemere and Cranleigh. We provide adult community health services in homes across Guildford and Waverley.
The Care Quality Commission (CQC) have given us an overall rating of Outstanding.
Royal Surrey has a strong reputation and history to build on. We are proud of our achievements and we are investing in our colleagues through our commitment to supporting professional development as well as investing more than £45 million in our physical environment and new equipment in the next few years. There has never been a better time to join us.
Although it isn't the Trusts normal practice, adverts may close early, so you are encouraged to submit an application as soon as possible.
A video about the Royal Surrey - https://www.youtube.com/watch?v=R96pMboIYdo
Detailed job description and main responsibilities
Band 6 Complex Case Manager. Permanent FT 37.5 hours per week
Due to redesign within our service we are developing a team to support the most vulnerable patients in their transition from the acute hospital to home or other care settings. The complex discharge team will complement the work of the established case management team and the discharge hub within the Royal Surrey working across all acute inpatient areas including Milford and Haslemere Hospitals.
This service demands a blend of clinical expertise, coordination prowess, and compassion to facilitate safe and effective discharges for complex cases, including CHC complex and fast track in addition to self-funders. The service will also include development of a care home liaison service, providing support to those admitted from care homes, liaising directly with medical teams and care homes to reduce length of stay and provide seamless care.
Key Responsibilities
· Coordinate complex discharge planning processes, collaborating closely with multidisciplinary teams, patients, and their families.
· Conduct comprehensive assessments to identify patient needs, including social, psychological, and physical aspects impacting discharge plans.
- Develop individualised discharge plans that prioritise patient safety, continuity of care, and adherence to clinical protocols.
- Early identification for patients from care homes, liaise with medical team and care home to ensure adequate information is gathered at the point of entry to the hospital.
- Liaise with services involved in the patients admitted from care homes, adult social services, CHC, care home matrons.
- Facilitate timely and smooth transitions by arranging necessary services and resources post-discharge.
- Maintain accurate documentation of discharge plans, assessments, and communications with stakeholders.
- Monitor and evaluate the effectiveness of discharge plans, making adjustments as needed to optimise patient outcomes.
As a Band 6 case manager you will be an experienced nurse or allied healthcare professional who has an understanding of the complexities of discharge planning and communication across the MDT and with patients, families and other agencies. You will work within a trusted assessor model and therefore in-depth understanding of complex needs assessment including MCA and best interest decision making is paramount. Support and training to develop knowledge and skills will be provided as part of the role.
There will be capacity for hybrid flexible working Monday-Friday 08:00-18:00 and Saturday 08:00-16:00 on a rota basis once every 4 weeks.
If you think this could be you and you would like to understand more or would like to have an informal discussion please contact Sarah Holbrook, Lead Nurse for Patient Flow on ext 6527/4519 [email protected]
Full details of the role, responsibilities and person specification can be found in the Job Description.
Please note interviews for this post will be held on Wednesday 14th August 2024, details to be confirmed if you are successful.
Person specification
Qualifications
Essential criteria
- Registered Nurse, Allied Health Professional or Social Care Practitioner
- Completion of Mental Capacity Assessment and Best Interest Decision Making training
Desirable criteria
- Evidence of Continuing Professional Development/Relevant Post Registration Qualification
Knowledge
Essential criteria
- Significant post qualification experience
- Demonstrable knowledge of the needs of patients and the key issues relating to discharge
- Demonstrable experience in communicating sensitive, highly complex and confidential information to patients and families utilising empathy and counselling skills
- Demonstrates experience in continuing to the development and implementation of standard operating procedures, guidelines and policies
- Experience in completing assessments in line with trusted assessor model
- Experience of completing mental capacity assessment and best interest decision making
- Demonstrate professional awareness and knowledge of relevant legislation and policies
- Can demonstrate up-to-date clinical credibility/competence
Desirable criteria
- Experience in line management or day to day management of staff
- Demonstrates an understanding of clinical governance and evidence based practice
- Understanding of issues within Acute trust and other relevant organisations
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.
Documents to download
Further details / informal visits contact
- Name
- Sarah Holbrook
- Job title
- Lead Nurse for Patient Flow
- Email address
- [email protected]
List jobs with Royal Surrey NHS Foundation Trust in Nursing and Midwifery or all sectors