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Swydd ddisgrifiad a phrif gyfrifoldebau manwl

Core responsibilities
• To follow the Trusts discharge policy and processes.
• In liaison with health and social care partners support the delivery of a high standard
of discharge planning across Kettering General Hospital ensuring safe and timely
discharges that ensures a positive experience for the patients and carers.
• Act as patient / carer advocate at all times.
• Where necessary, and in agreement with the multidisciplinary team, case manage
the discharge plans for identified patients with complex needs.
• To work with and motivate the multidisciplinary team to ensure discharge planning
takes place in a timely manner and takes into account all of the patient’s needs.
Also ensuring throughout the patient journey effective communication and strong
team working.
• To work closely with all Divisional teams and other relevant people to ensure delivery
of programmes of work, as agreed to support development of good discharge
practice in and across relevant professional groups and services.
• To act as a key contact with partner provider organisations in ensuring pathways
both to and from services work smoothly and prevent delays in transfers of care.
• To work collaboratively with colleagues across the social care, health and the
third sector to provide patient centered, integrated care.
• To manage and to co-ordinate a team of discharge coordinators in order to
ensure effective and efficient service delivery, development, and quality.
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• To ensure optimal use of resources in particular those related to discharge
pathway such as transport, acute beds and community capacity, voluntary sector
thus supporting patient flow through the trust.
• To participate in continuing professional development and other development
activities, including mentoring and to contribute to the professional development of
colleagues.
• Support Trust performance in achieving access targets in maximising and utilisation
of in-patient beds and reduction in length of stay and delayed transfers of care.
• Reassess patient and demonstrate the quality of service provided,
seeking opportunities to involve service users in this process.
• Work confidentially in accordance with the Data Protection Act.
• Identify the need for and ensure the timely onward transfer of information for
referrals which require comprehensive needs assessments by other members of
the Multi-Disciplinary Team.
• Ensure that all necessary patient information supporting, monitoring, and tracking
of discharge processing is recorded in an accurate, consistent, and timely
manner.
• Assist with monitoring the progress of referrals and ensure any subsequent reviews
are initiated and completed in a timely manner.
• Support the reporting requirements of the service as requested by the team leader.
Management, leadership and organisational
• To either coordinate directly, or support and enable members of the
multidisciplinary team to coordinate the complex discharge of patients. so that all
elements are in place to ensure a safe and timely discharge.
• Professionally responsible to ensure the post holder’s practice adheres to all trust
and national policies and procedures that are determined by other.
• Contribute locally to the implementation of relevant guidelines, national strategy
and legislation (reimbursement and delayed transfers of care).
• To comply with the Professional and Organisational Codes of Conduct and to be
aware of changes in these. To maintain up to date knowledge of all relevant
legislation and local policies and procedures implementing this to practice
• Required to ensure an adequate supply of community discharge information
leaflets and information resources for patients and relatives.
• Required to use own initiative, take responsibility for decision-making, and prioritise
own workload within a team context.
• Support and lead the discharge team in the absence of managers.
Required to bring to the attention of appropriate
managers/supervisors where workloads/pressures become such that an
appropriate level of safe and effective patient care cannot be maintained before
the situation becomes untenable.
• Able to provide advice, demonstrate own activities or workplace routines to visitors
to the department.
• Required to work with appropriate Trust documents (Clinical Guidance documents).
• To be able to assess, implement and evaluate the discharge needs of patients and
carers, and to refer for the provision of these care needs to appropriate members of
the multidisciplinary team.
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• Ability to act as discharge coordinator lead in a defined clinical area to ensure safe
and high-quality discharge practice is undertaken.
• Have knowledge of internal and external service teams and organisation that can
support aid in the discharge of patients and initiate referrals when appropriate.
• To supervise and train new and less experienced staff to aid their development of good
discharge practice.
Clinical
• Maintain a system for early identification and intervention for patients most at risk
of delayed or complex discharge needs.
• Attend ward board rounds and provide expert advice on matter of discharge
planning and problem solving on this subject.
• Manage the discharge of an identified group of patients by the coordination and
implementation of care plans in preparing patients for discharge or transfer,
recognising situations that may be detrimental to the patient’s health and safe
discharge, then to take appropriate action.
• Prepare patients and carers for transfer from hospital, maximising independence.
• Provide support and guidance to the multidisciplinary team, patients,
and carers/relatives regarding discharge/transfer of care planning.
• By liaising with the multidisciplinary team, support of discharge planning of patients.
• To support multidisciplinary teams in the identification of patients suitable for transfer
to community health settings.
• To support services and the management of referral information to any service
to enable the delivery of timely and appropriate response following referrals.
• To ensure that confidentiality of patient information is maintained, and that
written documentation is complete and up to date.
• To monitor and check the accuracy of referrals to partner organisations and
where necessary to undertake the referrals on behalf of the multidisciplinary
team.
• To ensure the Transfer of Care policy is adhered to and implemented where
necessary.
• To investigate complaints as delegated by the Discharge Manager in a timely manner.
• Attend and provide information to the bed meetings and any escalation meeting
as required.
• To be proactive in reducing delayed transfers of care and escalating where
necessary potential issues and taking action to reduce discharge delays.
• To promote and ensure maximal use of discharge lounge.
Service development
• To support the development of processes, policies and practices that ensure all
relevant assessments, services and resources are available, to ensure an appropriate
and safe discharge, taking into account the patients and carers needs.
• To support the audit and where necessary lead on, individual projects to monitor and
measure improvement in the effectiveness of discharge planning within the trust and
to collect and analyse relevant data.
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• To support the development of an improvement plan with specific targets and
timescales to reflect the focus on ensuring good discharge practice and the setting
and monitoring of quality standards.
• To contribute to the planning and development of the discharge service by
supporting a “whole systems approach” to the discharge planning process.
• Where necessary, contributing to system reviews and process improvement by
identifying areas for action and improvement and supporting change to meet
trust objectives.
• Assist in critical evaluation of effectiveness of service provision in terms of
patient/carer and organisational outcomes.
Knowledge, training, and experience
• Attend annual mandatory training/updates.
• To participate in regular supervision in accordance with good practice guidelines
and trust policy.
• To participate in Trust’s annual Appraisal processes.
• To have core knowledge of the Power of Attorney, Court of Protection, Mental
Capacity Act, and other relevant legal frameworks.
• To maintain and understand of how the role of other agencies can help in
supporting safe and timely discharge.
• To understand the services offered by non-acute health and social care settings
which can be used to support the transfer of care of patients from hospital.
• To appreciate and support the implementation of standard referral practice and
the sharing of relevant information that prevents multiple assessments.
• To provide on-going training related to discharge planning and promote an
environment that is conducive to learning.
Communication and relationship skills
• To provide support to ward teams to ensure high quality individualised
discharge planning for patients and relatives/carers and to contribute to the
continuing improvement and development of discharge processes and care
pathways.
• When needed to coordinate the ward multidisciplinary meetings.
• To support the implementation of the Trust’s Reimbursement Policy and
Delayed transfer of care reporting where necessary leading in negotiation
with partner organisations to gain agreement in Sitrep information.
• To be key contact with partner services in the referral process, negotiating
where necessary to agree plans for referral / acceptance of patients to
services.
• Where necessary work with Ward Managers and other members of the
multidisciplinary team to give feedback to team members to ensure
practice improvements.
• Liaise with partner services and professionals to ensure the trust is kept up to
date with the process of referral.
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• Proactively participate in ward board rounds and multi-disciplinary meetings to
support the trust red to green process to maintain the effective management of
bed capacity and flow across the trust in line with trust and national targets working
alongside the hospital and discharge coordinators.