Integrated Discharge Coordinator

2 weeks ago


Leamington Spa, Warwickshire, United Kingdom South Warwickshire University NHS Foundation Trust Full time
We are looking for a dynamic individual to join the Complex Discharge Team.


The team work across acute (Warwick Hospital), community hospitals and in specifically commissioned D2A care homes, located in South Warwickshire.


You will manage a caseload of patients by delivering a high-quality service, ensuring discharges are planned with a home first mind set, ensuring patients are discharged to the least restrictive option through several Discharge to Assess (D2A) pathways.


You will work collaboratively across all divisions within the Trust, whilst sustaining partnership working and links across the local health and social care economy.


Working with a variety of staff groups and voluntary sectors; you must be confident in sensitively challenging conventional thinking and demonstrate negotiating and influencing skills.


You will contribute to the redesign of discharge pathways and facilitate in the delivery of local and national legislation and guidance related to patient discharge.

Applicants with NHS Continuing Healthcare assessors experience very welcomed.

The service operates from Monday - Friday.

Applicants will also be expected to work an occasional Bank Holiday.


To coordinate complex patient discharges by liaising across the Health and Social Care economy and working collaboratively with Primary Care and third sector services, This is an integral role provided at both the acute sector and the community setting.

The purpose is to assist the Trust to maintain capacity and flow throughout the whole system and to promote safe and timely discharges, with the intent to reduce the detrimental outcomes associated for patients who have a prolonged length of stay.


The Trust have a number of discharge initiatives that aim to bring care closer to home, therefore the post holder must be confident and proactive in sensitively challenging conventional thinking.

Come and join a Trust rated Outstanding by the CQC.

South Warwickshire NHS Foundation Trust have been rated as outstanding following our latest inspection by the CQC and we are recruiting new staff to come and help us improve even further.


We provide services across Warwickshire and beyond ranging from Hospitals in Warwick, Stratford-Upon-Avon, Royal Leamington Spa and Shipston-on Stour to Community Services across the county.

We are a progressive, expanding organisation with great ambition around improving quality, integrating pathways and delivering high levels of productivity.

Our values can be summed up in one sentence. We are 'Trusted to provide safe, effective and compassionate care'.

Throughout the recruitment process you will be asked to think about how you demonstrate these values and how they impact on your work.

It doesn't matter what role you do, whether it is patient facing or not, we are all working in the same way with our values at the core.

Work independently managing own allocated case load.

To respond to referrals within 1 working day, notifying Discharge Team Manager/ Leader immediately should this not be achievable.

To work towards the specified Estimated Discharge Date (EDD) identified by the Clinical/ Multidisciplinary Team.


Review daily, each complex patient's progress towards discharge to determine if the plan needs to be revised and actioned in order to achieve a timely and safe discharge.


To prepare complex patients and their relatives at the earliest opportunity in relation to planning for discharge - ensuring the philosophy of assessments taking place closer to home is reiterated rather than in the hospital setting.


To support ward staff and assist in coordinating patient discharge for those entering 'end of life, liaising with necessary partners and organisations such as Continuing Health Care, local hospices, District Nurses, Voluntary sector and Charitable organisations.


Ensure the 'discharge database' is accurately completed and up-dated to enable Delayed Transfers of Care patients and the reason why they are delayed to be identified and counted on a daily basis.


To identify appropriate patients through the 'trusted assessment' process to the various 'Discharge to Assess' initiatives to bring care closer to home for patients.


To undertake Mental Capacity assessments in accordance with the Mental Capacity Act in relation to specific decisions pertinent to the patients discharge plan.


To lead and coordinate the NHS Continuing Health Care process in accordance with 'The National Framework for CHC' and based on the 'trusted assessment' agreed with SWCCG.

To inform and provide the Team Manager/ Leader with all data required to prepare the weekly SITREP report on Delayed Discharges in accordance with the Care Act


To escalate to the Team Manager/ Leader patients declining to leave an acute or community bed will require choice directive.

To undertake or deputise for some aspects of the Team Leaders role when necessary, such as attending meetings.

To cover and rotate

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