Discharge Facilitator

To actively participate in and investigate complaints which specifically involve a transfer of care process issue. To maintain accurate and contemporaneous records relating to individual patient transfers of care. In collaboration with professional colleagues to proactively manage and negotiate complex transfers of care e.g. social care packages and appropriate placements and care for disadvantaged patients e.g.

the homeless. Other relevant issues e.g. on-going care, convalescence, rehabilitation and respite/ interim repatriation. Responsible for the risk stratification, assessment and coordination of discharge plans for patients are deemed as readmissions or at high risk of readmissions.

Responsible for case management of patients with a long length of stay, facilitate and educate knowledge of the multi-disciplinary team with regard to length of stay of complex cases To provide cover for the other discharge nurse specialists as required. To work within the Transfer of care team, attend and participate in the team meetings. To deputise and attend Trust and other management meetings for the Discharge Matron as required. To provide skilled evidence-based care, ensure all care planning is patient centred, dynamic and in accordance with Trusts policies and guidelines.

To demonstrate an analytical approach to clinical assessment of patients in the light of current research and resources. Identify and assess patients for suitable and safe transfer to community/social services beds or intermediate care. To promote and support patient advocacy, choice and self-empowerment and encourage patient independence, ensuring full engagement in decisions regarding their future care needs. Work in partnership with Social Services Departments to conduct joint assessments and promote understanding of roles as appropriate.

Provide a resource point and contribute to the development and delivery of education and training programmes for acute by working closely with the education facilitator within the team. Training and Development. Responsible for leading, developing and delivering the trust discharge teaching/training programmes at Directorate and ward level to ensure best practice in accordance with Princess Alexandras Discharge Policy, whilst ensuring that educational opportunities are maximised in order to develop transfer of care planning skills in others. To work as an effective member of the Transfer of Care Team, maintaining personal and professional development and contribute to the development of the team and its activities.

To participate in Directorate research and education relating to practice. To maintain own professional and personal registration and revalidation Lead teaching programmes with all Trust staff to ensure best practice in planning safe and timely patient discharges. Accountable for his/her practice and takes every reasonable opportunity to sustain and improve his/her knowledge and professional competence. To participate in the teaching programmes of learners in accordance with their objectives, working closely with the College/University Develop knowledge and practice in all aspects of patient discharges and long-term care arrangements.

To be a mentor/preceptor as necessary. Access professional support through clinical supervision. To contribute to induction of new hospital employees from all disciplines. Provide discharge planning training programmes and oversee training issues across the Trusts to ensure all professional needs are met, thus ensuring the Trusts discharge policies are adhered to.

Involvement in helping to co-ordinate and review strategy for the Transfer of Care Team and annually assist in reviewing the Discharge Policy and Procedure Participate in project work for service improvement Leadership Supervise and support the continuous development of team members. Participate in the Trust appraisal process to ensure that you receive and give constructive feedback to enhance personal skill set and the promotion of professional Integrated Hospital Transfer of Care Team. Act as a role model to staff on the ward and throughout the Trust by ensuring you demonstrate the trust values and behaviours and provide teaching and coaching to junior staff. Seek and provide supervision to ensure that personal clinical practice is continuously developing.

Actively participate in the recruitment and selection process for new posts within the Transfer of care team Lead the management of authorised leave within your small team including the managing of annual leave, study leave and sickness; to ensure that there is sufficient wider team coverage Complete the local induction process for any new team members. Provide leadership, support and guidance to staff in their probationary period completing relevant HR processes and paperwork to enable staff to progress. To carry out any other duties commensurate with the post.