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Job description

This is an exciting opportunity to join the Integrated Discharge Service (IDS) based at North Bristol NHS Trust and be a pivotal role in supporting the development of the Transfer of Care Hub.

The post holder will be either a Registered Nurse, Therapist, Paramedic or Social worker and will focus on enhancing the patient, carer, and family experience around being discharged from hospital. You will play a crucial role in ensuring that there are enough beds for patients that need them, and that the flow of bed availability is maintained.

This post will require you to work with a wide range of professionals from the health and social care system so you will need to be a confident communicator and bring with you a sound knowledge of complex discharge processes, although you will be supported to increase this knowledge to the level required for this post. You will have had experience of supervising and supporting team members (or the skills to do so if you haven’t previously had the opportunity) and you will have been involved in or have led change within a pressurised environment

The post requires an individual with the ability to work in the area of managing of complex discharge processes and a commitment to the further development of this essential service.

You will be a lead in:

• Championing the Home First ethos- ‘There’s no place like Home’
• Facilitating timely and appropriate discharges- enhancing the patient and staff experience
• Holding early discharge conversations and driving quality board rounds
• Driving ‘flow’- ensuring beds are available for people that need them by delivering timely discharges
• Bringing discharge expertise to conversations with patients, families and staff- including supporting Managing Expectations procedures

Applicants will need to be able to demonstrate effective communication skills with an ability to ‘think laterally’ and problem solve complex situations, focusing on how best to meet the needs of the individual.

You will be a role model for the Integrated Discharge Service and Transfer of Care Hub both within the organisation and the wider system

NBT Cares. It’s a very simple statement; one which epitomises how everybody across our organisation goes the extra mile to ensure our patients get the best possible care.

NBT Cares is also an acronym, standing for caring, ambitious, respectful and supportive – our organisational values.

And our NBT Cares values are underpinned by our positive behaviours framework – a framework that provides clear guidance on how colleagues can work with one another in a constructive and supportive way.

• To drive and deliver consistently high-quality Board Rounds on every ward, every day by providing coaching and mentoring to the ward MDT- assist with allocation of actions, holding individuals to account
• To be responsible for supporting early discharge conversations for every patient to ensure discharge from the hospital at the earlier opportunity and to ensure that families are engaged, along with the patient, in the process (when appropriate)
• To promote the effective completion of the Transfer of Care document for people with complex needs to ensure their needs are clearly described and identified
• To adopt and champion a ‘Home First’ approach to discharge
• To facilitate and deliver discharges for people with complex needs in a safe, timely and appropriate manner
• To provide an expert resource on all aspects discharge processes & community service provision to the MDT
• To work with colleagues to develop High Impact User plans for patients identified as high risk of repeat admissions with long length of stay
• To hold work with partners to support a caseload of highly complex individuals whose discharge may not be facilitated through the Community Transfer of Care hub. For example: • Homeless people with no health or care needs
• Self- funded patients
• CHC/Fast Track
• Complex mental health needs or people with a Learning Disability
• Local areas not covered by Community Transfer of care Hub
• Coordination of off -site bed bases such as NBT NWB
• To work collaboratively with Ward leads to implement and embed the Managing Expectations protocol on an individual basis, escalating to organisational leads appropriately where there is no resolution within an agreed time frame.
• To coordinate multi-professional care planning processes & meetings for highly complex patients with multiagency involvement, ensuring actions are identified and completed within an agreed time frame.
• To undertake training and development of new staff members & students through Trust and local induction processes around effective assessment of patient needs
• To escalate any concerns to the IDS Operational Leads in an appropriate timescale, whilst maintaining professional autonomy
• To be able to confidently advise on criteria and relevant processes for: • DOLs procedure
• CHC and CHC Fast Track
• Mental Capacity Assessment
• Mental Health Act
• Safeguarding
• Application of Consent
• Referral processes including Out of Area Services
• To support the wards in the process for restart of a Package of Care, ensuring the needs of the patient will be met and advising where a new referral may be required.
• To implement the BNSSG operational standards accurately and effectively ensuring codes are correctly recorded and therefore reflect an actual level of delay, and reporting identified trends to relevant heads of service.
• To facilitate actions for admission avoidance and proactively manage readmissions, as per the BNSSG-wide procedures
• To actively challenge and prevent the cancellation of any discharge, ensuring colleagues understand the risks of a person remaining in hospital longer than they need to
• To liaise, promote the use of and develop effective working relationships with a range of providers including care providers, 3rdsector services, housing, out of area Health and Social Care services, Drugs and Alcohol service etc- this will be enhanced through the creation of the Transfer of Care Hub
• To provide a 7-day service, liaising effectively with ward leads, particularly in times of escalation in the Trust
• To use specialist knowledge and experience to support the implementation of NBT policies and procedures to facilitate discharges
• To support and actively engage in the maintenance of accurate documentation within IDS such as discharge forecasting, stranded patient reviews and outlier progress
• To work within clusters providing support & supervision to other IDS team members to provide a self-supporting & resilient service
• To assist in the investigation and resolution of discharge related complaints and implement areas of learning that are identified to improve service provision

Communication and Information:

• To use excellent communication skills to collaborate within the IDS team and with partners within the Transfer of Care Hub to secure timely and safe discharges
• To adopt a professional manner in all verbal and other communication with partners and with patients, especially when sharing difficult, complex or emotive information e.g. when managing expectations