Caseworker - Hospital to a Healthier Home Service

3 weeks ago

Deeside, United Kingdom Care and Repair North East Wales Full time

**PURPOSE OF THIS ROLE**

The role holder is responsible for providing a dedicated and specialist casework service for the critical and prevention interventions to support a safe and timely hospital discharge which reduces which reduce any readmissions.

The purpose of the post is to work proactively with clients primarily but not exclusively older people, in both hospital and community settings, to improve their ability to live as independently as possible, for as long as possible, in their homes. This will be achieved by working within the existing local processes and pathways for health and social care, thereby identifying older people in priority need and providing individual clients with a coherent person-centred approach in which their specific needs are seamlessly considered, recognised, and responded to. The principal focus of the service is to provide bespoke home improvements and adaptations that support independence, however there are further outcome requirements related to prudent healthcare, new technology and access to services. Key to the approach is identifying with Health & Social Care partners those in critical need; ensuring effective service access to beneficiaries and tailoring interventions to the specific need.

To ensure a seamless service for clients being discharged from hospital or prevention of admission to hospital.

**Key accountabilities and responsibilities**
- To be the face and direct contact of the Hospital to a Healthier Home Service.
- To work when required within the local Hospitals.
- To work with the hospital teams, assisting with patients housing needs and solutions to meet those needs to enable discharge by the planned discharge date.
- Provide a point of contact for responding to clients or professionals calling the office in relation to urgent hospital works.
- Visiting clients on the wards to ensure we provide advice and personalised support to the client to identify their needs and discuss personalised options to repair or adapt their home.
- Proactively identify older frail patients with age-related challenges, complex health issues and related sensory loss, dementia or post-stroke trauma, that threaten their independence at home.
- Promote, provide awareness and develop referral protocols for potential clients with NHS, Social Care and Third Sector teams and establish a good working relationship within the relevant local authority departments, health services, housing and voluntary groups who are in contact with the client group.
- Work with the assessment and discharge planning processes within local clinical settings to assist in identification in a structured way, embedding a housing-related community service in the patient pathway.
- Provide a Healthy home visit assessment that is person-centred and needs-led, identifying housing, environmental and personal risks to independent living that clients face including assessing the risk of falls, and any factors affecting the safety, warmth and security of the property.
- Ensure that the client understands and is kept informed of all the procedures and practices involved with their particular circumstances.
- Deliver targeted information, signposting and support to those individuals identified with sensory loss, dementia and stroke (and their families and friends), to ensure they are aware of the services, information, advice and support available to them to enable them to live independently.
- Undertake brief interventions with people at high risk of losing their independence; this may include problem-solving with individual clients, supporting them to resolve issues relating to their sensory loss/dementia/stroke, living circumstance and independence, particularly at times of transition, such as hospital admission, diagnosis or discharge.
- Use Person-Centred approaches to plan, implement, monitor and review the support you provide.
- Work in a fully integrated way with other members of the local health and social care teams, to ensure people receive a seamless high-quality support, in which their living circumstance are considered as an integral part of their packages of care and support.
- Liaise with practical services/adaptations team or contractors to undertake relevant repairs and adaptations.
- Refer to specialist support such as the Managing better Caseworker to demonstrate assistive equipment to people which would enable them to live more independently and provide information and support services for clients that want to access new technology to support independent living.
- Have a basic knowledge of complex health and cognitive disorders, e.g. dementia, how the home environment might be improved to maximise opportunities for wellbeing and independence and how sensory loss impacts on these conditions.
- Ensuring the service runs in line with contractual and service level agreements.
- Provide information to the Client Services Manager and other bodies monitoring the projects performance.
- Keep up to d

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