Care Home Pathway Coordinator

Job overview

Care Home Pathway Coordinator

The Care Home Pathway Coordinator will be working with the Transfer of Care Hub (TOCH) and will coordinate all aspects of supported discharges and the single point of discharge from Croydon University Hospital (CUH) to care homes.

The service is to ensure care home residents are not unnecessarily admitted to, or delayed in leaving, hospital to the detriment of their wellbeing and independence. The post holder will seek to improve patient flow, reduce delayed transfers of care (DTOC) and avoid unnecessary readmissions, LOS reduction and reduce 4-hour breach for care home residents.

We are looking for an enthusiastic individual to take up the role of Care Home Pathway Coordinator. The post holder will be based at the CUH and will coordinate the activities related to the Red Bag journey for patients coming into the Hospital from care homes and ensure the Red Bags are received in the hospital and returned to the care homes on discharge of patients after hospital episode.

The post holder will work closely with all stakeholders to enable the successful delivery of the Hospital Transfer pathway and the Discharge Process for care home residents. . The post holder will facilitate the use of the Transfer Pathway and Discharge activities to support safe and quality care to patients admitted from and to care homes.

Main duties of the job

• 1.    Work closely with ward teams and Discharge Co-ordinators within the hospital to identify care home residents requiring discharge planning, ensuring their plans are kept up to date e.g., discharge summaries,  Universal Care Plan (UCP) and medication reviews before these patients are taken back home. 2.    Work collaboratively with the discharge teams and multi-disciplinary teams ensuring all discharge documents are finalised prior to the discharge of patients. 3.    Ensuring that the hospital teams have relevant information to assess and provide the appropriate treatment plan and that on discharge, care homes have the relevant information to enable continuity of care. 4.    Escalate most complex and challenging cases to Senior Discharge Co-ordinators for support or advice. 5.    To ensure smooth and timely communication between the Trust and partner agencies involved in patient discharge/transfer of care to avoid unnecessary delays. 8.    Ensure the Red Bag Checklist is reviewed, completed, and actioned by the designated responsible staff member when the patient is admitted and discharged.
• Ensure the Red Bag remains with the resident while in the hospital and return with a Red Bag containing all the relevant documentation, medication (if required) and personal items.
• Track usage of Red Bags and eRedBags by care homes.
• Support the process of the Red Bag Scheme in the hospital and SWL ICB including the eRedBag process.

Detailed job description and main responsibilities

• 1.    Review completeness of the Hospital Transfer Pathway documentation on arrival at the hospital and feedback to the care homes for incomplete documentation. 2.    Request vital missing information from the care home and develop an escalation process for raising this as an issue if it regularly occurs. 3.    Provide nursing discharge letter and work with the pharmacy team in the hospital to provide To Take Out (TTOs) on discharge of the resident. 4.    Ensure that the Hospital Transfer information is part of the assessment process for the care homes residents on arrival to the hospital. 5.    Ensure that the hospital team informs the care homes of the discharge process within 48 hours. 6.    Ensure the Red Bag includes the complete paperwork and personal items when the bag is returned to the care home with the resident. 7.    Track missing Red Bags within the hospital, liaise with care homes to return any missing Red Bags. Support the distribution of new, found or replacement Red Bags to care homes where needed. 8.    Liaise with care homes where needed to support use of Hospital Transfer and Discharge pathways, including training, care homes visits and promotion of relevant information. 9.    Work with hospital staff to ensure all stages of the Hospital Transfer pathway are completed to enable tracking and evaluation of the scheme. 10.  Promote and raise awareness of the Hospital Transfer Pathway, its use and benefits and its impact across the hospital, create resources and provide training to support this to hospital staff. 11.  Work with senior hospital staff, wards, and teams/departments to implement initiatives to support the successful implementation of the Hospital Transfer Pathway, this includes attendance to all relevant committees, groups and meetings and facilitation of the same. 12.  Act as a point of contact for all Red Bags matters within the hospital and provide advice, guidance and support to staff, family members and patients where needed. 13.  Attend regular meetings for the Hospital Transfer and Discharge pathways within the hospital, the ICB and other meetings, and maintain contact with colleagues. 14.  Facilitate safe and timely discharge of patients who are medically fit for discharge and ensure care home residents settle back into the care home to reduce LOS and DTOC. 15.  Work with other stakeholders to ensure relevant data is collected quickly and efficiently, is up-to-date and of a high quality and is used appropriately to support training, and implementation and evaluation of the Hospital Transfer Pathway 16.  Ensure completion of all discharge information to go with the care home patient prior to discharge of patients. 17.  . Ensure compliance with correct IG and data protection policies. 18.   Ensure completion of all stages of the hospital element of the Hospital Transfer and Discharge Pathways for care homes.