Complex Case Manager

Job overview

The post holder will assist and provide a proactive and efficient Complex Case Management Service for all adult patients across all ELHT hospital sites. They will provide education and advice to maintain a high standard of discharge planning processes. Ensure and promote the timely access to health and social care resources to enable the safe and effective discharge of patients from hospital. To work in partnership with other interdependent teams and services across the Health and Social Care Economy that are involved in the discharge planning of patients.

Main duties of the job

• To provide pro-active and responsive support to the Head of Complex Case Management.
• Work across all ELHT sites to meet the needs of an efficient Complex Case Management Service.
• Advise assist and navigate ELHT staff through the discharge planning process to plan and meet future care needs to facilitate a safe and timely discharge from hospital.
• To have the in-depth knowledge and skills to act as a resource for ward staff at all levels and other multi-disciplinary professionals ensuring there is a consistent and informed approach in relation to effective and timely discharge planning.
• Provide proactive input to all wards to ensure length of hospital stay is determined by clinical need and not by organisational resources.
• To promote and maintain effective communication channels between all Health and Social Care departments/agencies in the acute and community settings.
• Proactively advise and support staff to initiate the early discharge planning of patients with vulnerable/complex needs ensuring appropriate assessments are completed in a timely manner to facilitate discharge.
• Identify, progress chase and monitor delayed discharges and lost bed days within the patient journey and referrals.  In the absence of the Head of Complex Case Manager complete and submit the SitRep for Delayed Transfers of Care when required.

Detailed job description and main responsibilities

• Visit wards on a daily basis, working on own initiative under the direction of the Head of Complex Case Management to ensure discharge planning process commences as soon as possible after admission.
• Contribute to and lead, where necessary, daily board rounds on wards, encouraging active participation from MDT members.
• Prioritise own workload to ensure deadlines are met and a quality, responsive service is provided.
• Identify and discuss any potential discharge problems/delays with ward staff and patient/relatives to resolve issues as soon as possible.
• Alert the Head of Complex Case Management of any unresolved issues/conflict/barriers preventing resolution.
• Maintain accurate records and participate in internal or Department of Health audits as required in relation to the discharge planning process.
• Act in accordance with Code of Professional Conduct and ensure current registration is maintained.
• Identify patients approaching the end of life and initiate fast track processes to preferred place of care in accordance with The National Framework for NHS CHC.
• Support and respond to the Trust Escalation Processes, as guided by the Head of Complex Case Management /Head of Clinical Flow and maintain close liaison with Bed Management.
• Represent the Complex Case Team at bed meetings communicating appropriate and accurate information.
• Contribute to the maintenance of processes which support The Community Care (Delayed Discharge) Act 2003 and ELHT Patient Discharge Policy.
• Ensure compliance with other related Trust Policies and Department of Health Legislation with regard to discharge planning processes.
• Support the Head of Complex Case Management to implement strategies for ward staff and professionals to determine realistic discharge dates for timely and effective discharge planning patient flow.
• Screen referrals made to the Central Point of Referral in Complex Case Management, signposting to alternative pathways as appropriate to meet identified needs.
• Screening and tracking of referrals, monitoring assessment and transfer timescales.
• Maintain databases as required.
• Maintain accurate record keeping at all times.