Home First Therapist (OT/PT)

Job overview

• To undertake a comprehensive assessment of patients, including those with diverse or complex presentations/multi pathologies.
• To work with the acute Multi-Disciplinary Team & Transfer of Care Hubs to promote an efficient, effective discharge from hospital to the patient’s own home.
• To bring a holistic therapeutic approach to the multi-disciplinary team. Concentrating specifically on admission avoidance strategies and interventions.
• To have a role in the responsibility for the management of patients care pathway through the CIS services
• To be responsible for a designated caseload of patients, where you will implement and evaluate treatment plans, and coordinate interventions within Home First & Urgent Community Response.
• To liaise with health, and adult social care, working in partnership with primary and secondary care, social prescribers, and other external agencies to ensure the delivery of a high-quality service, and facilitate effective discharge from the Home First Service.
• To provide a specialist service to patients in their own home/usual residence
• To communicate effectively with patients and carers and allied agencies to maximise discharge and recovery potential and to ensure understanding of condition

Main duties of the job

• To be professionally and legally accountable for all aspects of own work, including the management of own patient caseload. To ensure a high level of care, and support more junior staff to do likewise.
• Promote a holistic, supportive, and patient cantered service that facilitates an intervention approach to promote change, acceptance and promotes self-management aiming to optimises functional improvement
• Work with Home First: supporting with triage, patient care pathway, and sharing knowledge related to the discharge to assess and admission avoidance strategies
• Work with patients, carers and families, and other statutory health related services
• Work autonomously and within the MDT team delivering individualised treatment interventions and management programmes
• Be flexible in the approach to delivering treatment and advice, have skills to deliver a variety of treatment interventions
• Have advanced communication skills that would include motivational and emotional support skills

Detailed job description and main responsibilities

• To be professionally and legally accountable for all aspects of own work, including the management of own patient caseload. To ensure a high level of care, and support more junior staff to do likewise.
• Promote a holistic, supportive, and patient cantered service that facilitates an intervention approach to promote change, acceptance and promotes self-management aiming to optimises functional improvement
• Work with Home First: supporting with triage, patient care pathway, and sharing knowledge related to the discharge to assess and admission avoidance strategies
• Work with patients, carers and families, and other statutory health related services
• Work autonomously and within the MDT team delivering individualised treatment interventions and management programmes
• Be flexible in the approach to delivering treatment and advice, have skills to deliver a variety of treatment interventions
• Have advanced communication skills that would include motivational and emotional support skills
• To use advanced clinical reasoning skills and assessment techniques to analyse and provide an accurate diagnosis of their condition.
• Manage a patient through the entirety of their care episode in relation to Home First assessment, symptom management, support and discharge.
• Where appropriate to work collaboratively with primary and secondary health care services, third sector services and social prescribing, education and social services, to ensure the delivery of a seamless and high-quality service.
• Have a broad skill set which can include advanced skills in delivering therapy intervention in order to provide a 2-hour urgent response for patients in a crisis.
• Manage severe complex, house bound patients. The CIS Home First service offers a domiciliary service to severely affected individuals; this requires collaborative working with social services and other attending care agencies.
• Be able to recognise the signs and symptoms of a deteriorating patient, having the skills to escalate accordingly.
• Be an advocate for the patient.
• Knowledge of where to sign-post patients for support, e.g. local or national support groups
• To be responsible for a caseload and work without direct supervision, and provide peer support for members of the MDT
• To ensure patient care and planned interventions are supported by available evidence base and experiential knowledge and are in accordance with Code of Professional conduct.
• To keep up to date and monitor literature related to Discharge to Assess and Crisis Response.
• To carryout risk assessment in line with Trust/National Protocol.