Integrated Transfer of Care Co-ordinator

5 months ago


Great Yarmouth, United Kingdom East Coast Community Healthcare CIC Full time

Communication Review all referrals for appropriateness ensuring all relevant information and assessments are completed and signpost on where needed. To receive and interpret/analyse sensitive information and accurately document information Excellent communication skills. Aim to develop and maintain effective interpersonal relationships with all members of the multidisciplinary team Actively give and receive constructive feedback Manage patient information and analyse referral information to make an informed decision Have a thorough understanding and knowledge of transfer of care pathways, criteria to reside and criteria for transfer of care Liaise with Operations centre and Virtual Transfer of Care Hubs Network and liaise with Social Care Colleagues and Care Agencies to source packages of care Liaise with voluntary services, housing and charities in order to support patients needs on transfer of care To maximise patient flow, admissions and transfer of cares and to utilise bed stock to maximum capacity according to referrals received Updates ward/PCH/Transfer of Care hub staff re referrals accepted/declined verbally and on S1 Patient Care Work as part of a team whilst taking independent responsibility for referrals Liaise with Health and Social Care colleagues, able to use escalation routes when delays occur e.g. awaiting Social Worker allocation, waiting a Mental Capacity Assessment (MCA) Contribute to daily board rounds for the East Place Intermediate care bds and Beds with Care, support transfer of care planning meetings, identify and discuss potential transfer of care issues at the earliest opportunity.

Ensuring Estimated Dates of Transfer of care are reviewed and updated accordingly Organise and facilitate planning meetings as required Participate in Place and partner calls giving clear and concise information on admissions. Liaise with NHS CHC team re packages of care and placements Contribute to supporting evidence to meet the Care Quality Commission (CQC) fundamental standards as required Understanding of multidisciplinary and integrated working proactively manage patient flow Acute to community Meet the demands of the pace of patient flow in the wider system Contribute to a professional working environment Professional Proactively Reviews Acute Hospital waiting list to seek out appropriate referrals for bed based rehabilitation Be able to analyse dashboard data and identify trends for onward discussion with service leads Communicate effectively, develop, and maintain productive working relationships with system partners Provides timely and accurate information re admission/referral information to daily system calls To facilitate early transfer of care from community hospital/beds with care Able to work flexibly and be able to adjust to constant changing demands of the role Act as a resource, advisor and role model to other colleagues in relations to patient flow processes Demonstrate a sound knowledge of the Care Act 2014 and NHS Continuing Healthcare (CHC) Utilise advanced decision making and problem solving skills when reviewing referrals Demonstrates a high level of judgement, acting autonomously within role to accept/decline referrals Support with the development of admission/transfer of care process/polices proposing any changes to the benefit of patient pathways Contribute to financial performance Contribute to efficient use of our resources All roles within East Coast Community Healthcare CIC (ECCH) require staff to demonstrate our Values and Signature Behaviours in the care and service they provide to patients, service users, stakeholders and colleagues. All members of staff should consider these as an essential part of their job role. Our Values outline the core behaviours that we can all achieve and are summarised as an acronym within the word CARE.

**These stand for**: Compassion, Action, Respect and Everyone. Underpinning our Values are our Signature Behaviours which highlight by taking the right actions we continue to build a strong culture. Our four Signature Behaviours are: Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together.



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