Highly Specialist Physiotherapist Rehabilitation Navigator

Job overview

Home First are really excited to be able to advertise for our first highly specialist, Band 7 Physiotherapist Rehabilitation Navigator post.

This role is a Fixed term contract, developed to respond to the demand of winter pressures and to trial the benefits of the navigator role for future development. Evaluation and feedback from this experience will be essential in shaping the rehabilitation offer in Milton Keynes.

Home 1st provides admission avoidance and early supported discharge assessment for access to community inpatient rehabilitation beds, for the people of Milton Keynes who have been admitted to acute services.

Providing leadership support to the organisational management of pathway 2, this role will require excellent communication and liaison skills enabling you to represent the community-based Home 1st teams. Working closely with the Milton Keynes Hospital Integrated Discharge Hub, your broad clinical experience will be vital in the decision-making and sign posting required to reduce barriers to accessing rehabilitation for the people of Milton Keynes.

Experience of triaging and prioritising referrals, managing waiting lists and understanding the national guidance on intermediate care and system flow for supported discharge are essential.

Main duties of the job

• To support the delivery of Home 1st Planned and Unplanned Care services in Milton Keynes considering the holistic management of those with long-term conditions and frailty.
• To provide highly specialist holistic assessments and deliver person-centred rehabilitation- based discharge planning advice to patients requiring supported discharge from Milton Keynes University Hospital (MKUH), providing in-reach support as required.
• To work in partnership with the integrated discharge and therapy teams at MKUH to support the case management of discharge plans for transfer to the community-based inpatient Seacole beds, for patients with complex frailty or social presentations.
• To work closely by liaising with other Home 1st Planned and Unplanned Care teams providing specialist support to expedite transfer of care
• To work in collaboration with Milton Keynes Council Social care teams to triage, allocate and respond to referrals requiring joint integrated care and therapy assessment in order to support discharge from hospital.
• To provide sign-posting advice to individuals seeking support from community services.
• To undertake all aspects of clinical duties as an autonomous practitioner.
• To communicate effectively and work collaboratively with all members of the multidisciplinary team both internal to CNWL and across partner organisations.
• To participate in development of the Home 1st service..

Detailed job description and main responsibilities

• To work with members of the Home 1st team to deliver seamless therapeutic

• To supervise and support development of Band 5 therapists on rotation

• To be professional and legally accountable for all aspects of your work including the delivery of highly specialist therapy intervention and caseload management of patients in your care.
• To use specialist professional and clinical knowledge across a range of procedures based on a sound knowledge of evidence-based practice and treatment options, using clinical assessment, reasoning skills and knowledge of treatment skills.
• To undertake comprehensive holistic assessment of patients to determine suitable management of their rehabilitation needs.
• Use clinical reasoning skills to triage and risk assess appropriate therapeutic intervention response times for patients referred to the Home 1st   services.
• To assess patient understanding of treatment proposals, gain valid informed consent and have the capacity to work within a legal framework with patients who lack capacity to consent to treatment.
• Use a range of verbal or non-verbal communication tools to communicate effectively with patients, relative’s, carers and other health and social care professionals to progress rehabilitation and treatment programmes and discharge plans as required. This will include patients who may have difficulties in understanding or communicating.
• To manage clinical risk within the Home 1st service waiting lists to prevent the deterioration of patients requiring therapeutic input.
• Following assessment, be able to prescribe, order and review the equipment needs for patients requiring supported discharge, that require high level equipment packages for discharge.
• To support in-reach assessment, to expedite discharge plans aligned with PW1 and PW2 requirements.
• To attend MKUH integrated discharge hub multidisciplinary meetings to represent community services in discharge planning for those with complex needs.
• On completion of risk assessments, be able to make recommendations to the multi-professional teams, about the level of support need required to meet individualised packages of care or admission to appropriate inpatient units on discharge.
• To be able to promote a risk enabling approach to staff to encourage therapeutic intervention and functional activities, preventing deconditioning and reducing length of stay.
• To be responsible for the safe and competent use of all appropriate equipment.
• Work collaboratively with the multi-professional teams, including GP’s, other clinicians, medical and therapy colleagues, social services and the voluntary sector to ensure needs led comprehensive treatment plans are in place.
• Provide a comprehensive and highly specialist level of communication / liaison between the MKUH Integrated discharge hub, CNWL Single Point of Access (SPA), Acute Adult Frailty Team (AAFT), Seacole Inpatient Units and the Virtual ward team to promote patients therapy requirements in treatment and discharge planning.
• To attend the Virtual Ward / AAFT / Inpatient multidisciplinary meetings as required.
• Ensure accurate electronic records are maintained timely and effectively. treatment plans in the transition from hospital to Seacole or home.
• Take part in service audit to assess the effectiveness of the Home 1st clinical pathways.
• To work collaboratively in partnership with CNWL, MKUH and BLMK ICB to implement system flow response as part of escalation processes.
• To actively seek patient and carer feedback, to enable informed decision-making when reviewing service interventions.
• To take responsibility for analysis of Datix incidents regarding patient discharge from hospital and implement recommended actions to prevent recurrent risk.