Transfer of Care Navigator

Transfer of Care (Discharge) Pathway Navigator

Previous applicants should not apply.

We are looking for confident, committed and caring individuals to work directly with some of the most vulnerable adult patients, and their families, to help them achieve safe, effective and timely discharges from Guys and St Thomas’ NHS Foundation Trust.

**We know that delays in discharge for patients contribute to**:

- poor patient experience
- potentially lead to poorer patient outcomes
- operational bed flow issues for acute trusts, affecting other patients

It is therefore in everyone’s interest, patients, staff and the Trust to make transfer of care as effective and efficient as possible.

If successful, you will be working directly with senior ward staff on the wards, but will also work in close co-ordination with the Trust’s in-house specialist discharge team at the Internal Flow Hub as well as maintain regular liaison with community and social care teams, therapists and other multi-disciplinary groups. Effective communications skills are essential, as is a positive, co-operative attitude to problem-solving. The post holder will be required to work weekend shifts occasionally as we provide a 7 day service and will be based on the ward.

Clinical or previous social care experience is desirable but the work would also suit individuals with a strong admin background who now wants a challenging role on the interface between the clinical, and social, care spheres.

General Duties
- Plan and manage timely and appropriate transfers of care (discharge) from hospital.
- Identify complex discharges and alert the Internal Flow Hub.
- Liaise with patients and their relatives to provide comprehensive information on all discharge arrangements and services both verbally and in writing, including service contact details, out of hours numbers, names of key workers where relevant/known.
- Work actively with the MDT, Transport, other Trust departments, the Internal Flow Hub to support safe and effective discharges, identify, track and case manage complex discharges to prevent Delayed Transfers of Care (DTOC).
- Provide a single point of contact for wards and ensure that processes and systems are adhered to.
- Provide cover for other Transfer of Care Pathway Navigator colleagues

Skills/Knowledge/Ability
- Ability to work as part of a team as well as using own initiative
- Excellent organisational skills and attention to detail
- Confidence in making decisions when dealing with competing priorities
- Excellent command of written and verbal English
- Able to demonstrate excellent written English including grammar, punctuation and structuring written text
- Ability to work methodically in a busy environment and meet deadlines
- Ability to develop and maintain good working relationships with all levels of staff
- Ability to handle confidential and sensitive information appropriately

The Discharge Hub service is composed of a multidisciplinary team of Discharge Coordinators, Social Workers from Lambeth and Southwark, Occupational Therapists, Intermediate Care representative from Lambeth, and the Red Cross team.

The Wards are focused on multidisciplinary working and staff are expected to work very closely with Clinicians, Physiotherapists, occupational therapists, Specialist Older Persons Teams and the Internal Flow Hub.

Our values help us to define and develop our culture, what we do and how we do it. It is important that you understand and reflect these values throughout your employment with the Trust.

**The post holder will**:

- Put patients first
- Take pride in what they do
- Respect others
- Strive to be the best
- Act with integrity

Please see attached job description for further information on what the main responsibilities of this role are.