Integrated Discharge Service Co-ordinator

5 months ago


Bristol, United Kingdom North Bristol NHS Trust Full time

To have early conversations with patients and families/ carers around discharge and use this information to support the persons journey whist in hospital, adhering to the Home First discharge ethos Supporting and working in partnership with other members of the Integrated Discharge Service (IDS), Ward Multi-Disciplinary Team (MDT) and Community partners, constructively challenging where appropriate, the decisions with regards to discharge planning Be an active member of the newly formed Transfer of Care Hub (ToCH) Undertake baseline assessments in partnership with other members of the MDT ensuring that the admission and social assessments are available within 24 hours of the admission Prompt the MDT to always ensure the patient and their family are actively involved in their discharge planning and are always kept informed any updates or changes to the plans Represent the Integrated Discharge Service (IDS) at ward daily board rounds and actively participate to drive timely discharge Provide effective & timely communication of discharge actions, including action owners and timeframes with MDT team members and Case Managers and liaise with the nurse in charge/coordinator and consultant to update on actions required to expedite safe discharge. Meet daily with the Case Manager for the allocated Cluster to review patient progress and escalate concerns Post holder will escalate problems in discharge to the case manager or ward team as appropriate. Recognise the need for and undertake referrals to specialist practitioners/ therapists as appropriate. Participate & support case managers in ward education programmes to develop knowledge and understanding of complex discharge management including Single Referral Forms (SRF) completion and managing patient expectations.

Support ward teams to ensure that Flow Board information is up to date at all times and any changes are modified in a timely a manner when needed e.g. not only updated at board rounds The post holder will ensure patients and carers are aware of their Estimated Date of Discharge (EDD). Provide patients with written discharge related information e.g. Trust Discharge leaflet, pathway specific leaflets etc as appropriate Demonstrate a variety of communication skills in accordance with the patient group Support ward MDT colleagues to populate the Transfer of Care Documents (ToC Docs) & Continuing Health Care (CHC) referrals Support ward MDT colleagues to review Transport requests & check bookings made at the earliest opportunity Review patient Criteria to Reside (C2R) coding with ward staff, case manager & integrated discharge team and assist in updating the information, as appropriate Liaise with Care Homes / Home Care providers to ensure timely ward assessments and plan transfer when accepted by the provider Liaise with the IDS admin team and ensure that they are aware of all known planned complex discharges Maintain clear concise patient records and documentation adhering to the Hospital Discharge and Community Support: Policy and Operating Model and other Trust policies and procedures.

Provide concise handovers to other members of the MDT and escalate any delays in patient discharge to the Cluster Case Manager



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