Clinical Support Specialist - Homeless Care Coordinator

Job overview

Are you passionate about improving outcomes for some of the most vulnerable patients in our healthcare system?

We are seeking a proactive and highly motivated Homeless Care Coordinator to join our Transfer of Care Hub (TOCH) at North Middlesex University Hospital. This is a high-impact, system-facing role focused on improving discharge outcomes for patients experiencing homelessness.

You will play a critical role in addressing delays in discharge that impact bed capacity, patient flow, and system performance across North Central London.

Main duties of the job

• Manage a caseload of patients experiencing homelessness
• Complete and oversee Housing Checklists
• Coordinate multi-agency discharge pathways
• Escalate and resolve barriers to discharge

• Contribute to BCF reporting and performance metrics
• Support development of homeless discharge pathways at NMUH

Detailed job description and main responsibilities

Specialist Case Management & Discharge Coordination

• Lead identification and proactive management of patients who are homeless or at risk of homelessness from admission.
• Undertake comprehensive assessments to inform safe and effective discharge planning.
• Manage a complex caseload requiring coordinated multi-agency input.
• Attend board rounds, TOCH meetings, and escalation forums to drive discharge outcomes.
• Ensure all discharge plans align with Trust policy and national discharge guidance.

Statutory Duties and Housing Processes

• Take responsibility for completion and quality assurance of the Housing Checklist.
• Lead on initiation, submission, and tracking of Duty to Refer (DTR) referrals.
• Ensure compliance with statutory responsibilities under the Homelessness Reduction Act 2017.
• Maintain oversight of all housing referrals to ensure timely progression.

System Navigation & Multi-Agency Coordination

• Act as the Trust’s key point of contact for homelessness-related discharge issues.
• Work collaboratively with: Local Authority Housing Teams Housing Intermediate Care Team (HICT) Adult Social Care Voluntary sector partners
• Local Authority Housing Teams
• Housing Intermediate Care Team (HICT)
• Adult Social Care
• Voluntary sector partners
• Proactively follow up with Local Authority Housing Teams to confirm receipt, track outcomes, and challenge delays.
• Coordinate discharge pathways including interim accommodation and step-down care.

Escalation, Influence and Flow Management

• Identify and resolve barriers to discharge.
• Escalate delays through Trust and system escalation processes.
• Influence decision-making across organisations to improve patient flow.
• Contribute to reducing length of stay and delayed discharges.

Patient Advocacy, Safeguarding and Inclusion

• Advocate for vulnerable patients including those with mental health needs, substance misuse, and NRPF.
• Ensure safeguarding and Mental Capacity Act (MCA) processes are applied.
• Promote dignity, inclusion, and person-centred care.

Data, Performance and Governance

• Maintain accurate records of housing-related activity.
• Monitor and report on: Duty to Refer compliance Housing Checklist completion Discharge delays
• Duty to Refer compliance
• Housing Checklist completion
• Discharge delays
• Contribute to BCF reporting and Trust performance frameworks.
• Ensure compliance with information governance standards.