Integrated Discharge Service Coordinator

Job overview

We are looking for candidates to join our expanding integrated discharge (IDS) team and support the development of the transfer of care hub.

You will be crucial in ensuring that patients get to go home through a timely, safe and effective discharge process.

This patient facing role involves discussions with patients, their families and liaising and coordinating with multiple teams across the trust and partners across Bristol, North Somerset and south Gloucestershire (BNSSG). This allows allows us to ensure patients are discharged from the hospital at the earliest opportunity and that beds are made available to those that need them.

Candidates should have the following skills and experience

educated to GCSE standard to include English

IT Skills, basic word, email, keyboard skills, data collection

Able to mange conflicting demands

confidence to engage with multiple professionals

Adaptable to changing operational requirements

knowledge of patient admin systems i.e. care flow workspace

Previous knowledge of care work or clinical environment (desirable)

Previous applicants need not apply.

Main duties of the job

In this vital role, you will:

. working in partnership with other members of the integrated discharge service (IDS), ward multi-disciplinary team (MDT) and community partners, to support decisions with regards to discharge planning.

. Represent the IDS team at ward daily board rounds.

. Provide effective & timely communication of discharge actions using existing communication tools.

. Be expected to undertake a range of duties without direct supervision, with early identification of any needs required to support discharge, whilst being able to recognise when escalation for support outside of your scope of practice , regarding discharge.

Recognise the need for and undertake referrals for additional assessments and treatments.

Detailed job description and main responsibilities

• To have early conversations with patients and families/ carers around discharge and use this information to support the person’s journey whist in hospital, adhering to the ‘Home First’ discharge ethos
• Supporting and working in partnership with other members of the Integrated Discharge Service (IDS), Ward Multi-Disciplinary Team (MDT) and Community partners, constructively challenging where appropriate, the decisions with regards to discharge planning
• Be an active member of the newly formed Transfer of Care Hub (ToCH)
• Undertake baseline assessments in partnership with other members of the MDT ensuring that the admission and social assessments are available within 24 hours of the admission
• Prompt the MDT to always ensure the patient and their family are actively involved in their discharge planning and are always kept informed any updates or changes to the plans
• Represent the Integrated Discharge Service (IDS) at ward daily board rounds and actively participate to drive timely discharge
• Provide effective & timely communication of discharge actions, including

action owners and timeframes with MDT team members and Case

Managers and liaise with the nurse in charge/coordinator and consultant

to update on actions required to expedite safe discharge.

• Meet daily with the Case Manager for the allocated Cluster to review patient progress and escalate concerns
• Post holder will escalate problems in discharge to the case manager or ward team as appropriate.
• Recognise the need for and undertake referrals to specialist

practitioners/ therapists as appropriate.

• Participate & support case managers in ward education programmes to develop knowledge and understanding of complex discharge management including Transfer Of care Document (TOCDOC)  completion and managing patient expectations.
• Support ward teams to ensure that Flow Board information is up to date at all times and any changes are modified in a timely a manner when needed e.g. not only updated at board rounds
• The post holder will ensure patients and carers are aware of their Estimated Date of Discharge (EDD).
• Provide patients with written discharge related information e.g. Trust Discharge leaflet, pathway specific leaflets etc as appropriate