Care Home Pathway Coordinator

Job overview

Care Home Pathway Coordinator

The Care Home Pathway Coordinator will be working within the At Home Team closely with the Transfer of Care Hub (TOCH) and will coordinate all aspects of supported discharges and the single point of discharge from St Helier Hospital 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 St Helier Hospital 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

Sutton Health and Care is an innovative partnership of providers working across Sutton (GP Federation; Local Authority; Mental Health Trust and Acute Trust) to provide integrated services for the local community. As partners we have the exciting opportunity to put the shared vision for how health and care can be delivered into reality through the implementation of a service model for the provision of community services (adult and children) that truly integrates health and care, physical and mental health and primary and acute care.

We are committed to working with each other and commissioners to co-create a model which when implemented will transform the experience of the people who use services in Sutton and fit the vision of the Sutton Health and Care Plan and the national NHS Long Term Plan.

We firmly believe that the partnership will drive transformational change to the benefit of patients and the local health and care system, getting the system to deliver better person-centred outcomes and financial sustainability.

Detailed job description and main responsibilities

Role/Advert

• 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.
• Work collaboratively with the discharge teams and multi-disciplinary teams ensuring all discharge documents are finalised prior to the discharge of patients.
• 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.
• Escalate most complex and challenging cases to Senior Discharge Co-ordinators for support or advice.
• To ensure smooth and timely communication between the Trust and partner agencies involved in patient discharge/transfer of care to avoid unnecessary delays.
• 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.

Applicant requirements

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.