Discharge Navigator

4 months ago

London, United Kingdom King's College Hospital NHS Foundation Trust Full time

The postholder will be responsible for supporting discharge and flow for patients being seen by the RAAR - Rapid Access to Rehabilitation Team based at the Denmark Hill site. The RAAR Team is an interdisciplinary team of rehabilitation professionals including occupational therapy, physiotherapy, psychology, speech and language therapy, rehabilitation nursing and therapy support workers, all overseen by rehabilitation medicine consultants. The RAAR team provides rehabilitation to inpatients with complex rehabilitation needs including brain injury, spinal cord injury and polytrauma.

The postholder will support flow and discharge for patients under the RAAR Team, including those going to another rehabilitation facility, and those that are discharged straight home with community support.

The role would suit someone with experience of the different pathways for patients with complex neuro-rehabilitation needs.

For patients being discharged to another facility, tasks will include supporting timely and accurate referrals to neuro-rehabilitation units using the Badgernet referral system, assisting with completing, sending and following up referrals to specific units, and maintaining a database of the patient discharge journey in order to assist the team in managing flow.

For patients being discharged home, tasks will include assisting in identifying, liaising with and referring to community based services including community rehabilitation teams, social services, third sector agencies and mental health supports, organising family and discharge meetings, and liaising with the site discharge coordination team including the complex discharge support worker.

The role encompasses some patient facing work including supporting patients on the day of discharge, and supporting patients with tasks during the admission such as attending appointments, assisting them to engage in leisure tasks or referrals to third sector supports.

King’s College Hospital NHS Foundation Trust is one of the UK’s largest and busiest teaching Trusts with a turnover of c£1 billion, 1.5 million patient contacts a year and around 15,000 staff based across 5 main sites in South East London. The Trust provides a full range of local and specialist hospital services across its different sites.

King’s is committed to delivering Sustainable Healthcare for All via our Green Plan.

Our values at King’s, are that we’re a kind, respectful team;
Kind. We show compassion and understanding and bring a positive attitude to our work

Respectful. We promote equality, are inclusive and honest, speaking up when needed

Team. We support each other, communicate openly, and are reassuringly professional

The trust-wide strategy Strong Roots, Global Reach is our Vision to be BOLD, Brilliant people, Outstanding care, Leaders in Research, Innovation and Education, Diversity, Equality and Inclusion (EDI) at the heart of everything we do.

King’s is dedicated to embracing the broad diversity of our staff, patients and communities and stand firmly against all forms of prejudice and discrimination. This includes, but is not limited to, racism, ableism, homophobia, biphobia, transphobia, sexism, ageism, religious discrimination, and any other prejudiced behaviour that undermines the rights, wellbeing and identity of our staff, and patients.

Main

**Responsibilities**:
Clinical responsibilities
- To gain and maintain knowledge of rehabilitation units, services and their service remits
- To support the RAAR team identifying patients requiring rehabilitation referrals by being a source of information on units, admission criteria, waiting times and other relevant information
- To plan, organise and efficiently coordinate the referral process in liaison with the referring RAAR team members
- Ensure therapy rehabilitation referral and transfer documentation is complete, updated and timely.
- Refer and liaise periodically with rehabilitation services to determine outcome of referral for each patient. Inform of patient’s transfer to local hospital where this is the case.
- To escalate where delays to transfer exist
- Query and escalate any internal or external delays in referral process, funding process, acceptance, movement on waiting list, transfer, etc.
- Keep up to date with patient’s rehabilitation progress, medical status, on-going needs for specific rehabilitation services and change of plans.
- Discuss with therapists any discrepancy between patient’s reported needs and service available/delivered (in rehabilitation unit).

Update Multidisciplinary team of progress through written and verbal communication on a daily basis
Maintain close links with relevant discharge coordinators, RAAR administrator, rehabilitation units and ward and flow nursing staff
Escalate any complex discharge (that doesn’t relate to rehabilitation needs) to therapists and Discharge Coordinator and agree plan of action.
Report any delays in the rehabilitation referral process.
T

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