Transfer of Care Co-ordinator

Job overview

The Integrated Transfer Team are looking for a highly motivated and enthusiastic nurse to join our new team .

This is a really exciting time to join our team to become part of our integrated service as we have many new and exciting initiatives to challenge and develop our staff .

The candidate should demonstrate strong communication/negotiating skills and be able to work closely with members of the MDT and other stake holders to facilitate timely and safe discharges to aid patient flow within the hospital.

You will provide clinical leadership, expertise and advice to staff pertaining to all matters of discharge, quality and safe patient flow. The post holder will facilitate initial proactive assessments for inpatients in order to facilitate a safe, effective discharge from hospital and prevent avoidable readmission to hospital.

Main duties of the job

The key aims are as follows :

• Delivering a consistent, co-ordinated approach to assist patients to identify potential needs at the point of discharge to avoid unnecessary delays in transfer of care
• Working collaboratively with external and internal partners for the benefit of the patients to ensure smooth transition from hospital and reduce risk of readmission
• Transparently providing information and expert advice to patients, carers and other professionals
• Reporting all delayed transfers of care, sitrep reportable and non sitrep reportable, as per the local delay standards and criteria
• Act as a Leader for Palliative Care Discharges
• Act confidently as a Trusted Assessor and be a positive role model for the ITT

We are looking for someone who is driven to provide the best possible care for patients in the later stages of their stay in hospital and act in a professional manner at all times in line with Trust values.

The Integrated Team operates 08:00-18:00 seven days a week.

Detailed job description and main responsibilities

 To co-ordinate and manage the discharge process for patients with complex health care needs  To complete trusted assessment for patients pathway 1-3  To co-ordinate complex continuing care assessment, ensuring that the criteria is applied  consistently.  Aid compliance with the Discharge protocol across the Trust and wider community.  Assist with Trust wide capability to meet its demand for beds by ensuring timely and appropriate  discharges  Provide training and advice to healthcare professionals on all aspects of the discharge process  Assist with data collection and evaluation, including SITREP reports  Work in partnership with health, social and voluntary agencies to facilitate a seamless pathway of  care for patients  To support and mentor ward trackers  Provide Leadership and manage the process for patients on Rapid End Of Life discharges

The Trust is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expects all staff and volunteers to share this commitment and promote safeguarding by implementing the Trust’s policies and procedures, acting promptly on concerns, communicating effectively and sharing information appropriately.

If successful this vacancy will require an enhanced DBS check at a cost of £54.50. This cost will be deducted from your first Trust salary

In addition to this it will be a condition of your employment that you will join the DBS update service and pay the annual subscription fee of £16.