ICS Discharge liaison Nurse

Job overview

An exciting opportunity to join a wonderful, dynamic and patient focused team providing high quality services to the Walsall community.

Whether it be supporting a team member with new skills or attending to a patient and advising their family, your role as a ICS Discharge liaison Nurse provides you with the opportunity to deliver a high standard of care to patients in their homes (pathway 1), and patient’s that require comprehensive holistic clinical assessment and monitoring in the ICS pathway 2 and 3 beds, alongside developing your leadership skills supporting your team.

To provide a case management approach to care for an identified number of patients working closely with Acute Hospital colleagues and other Statutory and Voluntary agencies for patients on the ICS pathway 1-3.

To provide clinical advice, information and education to patients and carers with the aim of enabling patients to promote maximum independence, health and well being. To enable patients living with long term physical health challenges to live well within their communities, with a focus on not only their physical health needs but also their wider holistic needs, e.g. mental health, learning disabilities, psychological needs, social needs and spiritual needs.

Main duties of the job

To work within the multi-disciplinary team to provide senior nurse advice and expertise in relation to complex discharge planning. To complete comprehensive, holistic assessments and care plans to facilitate safe and timely discharge for Walsall residents in the Walsall area and in the Out of Borough Hospitals. Actively promote early and timely discharge planning within the Trust. Support junior members of the team to promote quality and embed the ethos of ICS.

To follow patients up in community and complete further assessments to support exit from ICS pathways, this includes Trusted assessments, Continuing Health care checklists and Decision support tool assessments.

Detailed job description and main responsibilities

• To work within the Intermediate Care Services team at a senior nurse level to monitor high standards of care and to facilitate evidence based appropriate/timely discharge underpinned by quality of care.
• To promote ICS Ethos of Home First.
• To work within a multi-agency integrated team at a senior nurse level, adopting a ‘no blame’ culture and act as a role model to junior staff.
• To assess Patients for Funded Nursing Care (FNC) determinations and Continuing Health Care (CHC), Decision support tool assessments (DSTs), CHC Fast Track Tools and oversee / advise on assessments completed by junior nursing staff.
• To work closely and build rapport with the Intermediate Care Team and other community-based services to support a seamless transition and prevent further admission to acute care.
• To support and supervise junior members of the team.
• To complete follow up assessments post discharge as part of a multi-agency team.
• To assess patients within the Trust for equipment needs and pressure relief equipment before their discharge home.