Discharge Planning Nurse

Job summary

The Specialist Discharge Planning Team at WSFT is a small team of experienced staff with a variety of backgrounds, who work together towards an aim of providing a safe, effective, and timely transfer of care for our patients. Primarily working with patients with complex needs, and those reaching the end of their lives, we work closely with the members of the multidisciplinary team (MDT), especially the other members of the wider Transfer of Care Hub (TOCH).

Although it can be challenging, our aim is to assist with patients experiencing an optimal length of stay in hospital. Delays in this, which lead to an overall longer length of stay in hospital, is not only a significant concern for frontline staff, but also can have adverse effects on patients, relatives, and the wider system.

We are seeking an ambitious, organised and highly motivated registered nurse who recognises that good discharge planning is an important part of the patient experience and can work as part of a fast-paced team.

You will work closely with the MDT in the acute Trust, external stakeholders, our community bed bases, and our commissioned beds, all to co-ordinate safe and effective discharges - ensuring the needs of patients with complex discharge arrangements are met in a timely manner.

Main duties of the job

Some of the main duties of a Specialist Discharge Planning Nurse are:

Completion of patient assessments and onward referrals

Working closely with other members of the TOCH to support discharges, and as part of the wider MDT to establish safe discharge plans for patients

Close communication with patients and families to agree safe discharge routes

Completion of mental capacity assessments (MCA's) and best interests decisions for discharge destination

Attending a variety of patient meetings - including patient review meetings, alongside family, MDT and professional meetings

Management of own workload/caseload

Attending board rounds, and engaging other members of the MDT in having a discharge planning focus when discussing patients

Acting as a source of information and advice on discharge planning and the TOCH

Establishing good working relationships and building trust with external stakeholders

Monitoring quality of discharges, and providing onward support when discharges have not gone to plan - including the completion of Datix's when this occurs

Supporting patients discharges by ordering appropriate equipment for discharge

Working closely with the Continuing Health Care (CHC) teams, and the Local Authority

Supporting team members and peers

Assistance with reduction of length of stay within the Trust

About us

#BeKnown at West Suffolk NHS Foundation Trust. By us. By our patients. By our community

We are a busy, friendly, rural NHS Trust providing high-quality care and compassion to more than a quarter of a million people across west Suffolk. We care for, treat and support people in hospital, at home and in various community settings.

The West Suffolk Hospital in Bury St Edmunds provides acute and secondary care services (emergency department, maternity and neonatal services, day surgery unit, eye treatment centre, Macmillan unit and children's ward). It has 500+ beds and is a partner teaching hospital of the University of Cambridge.

Adult and paediatric community services, provided in collaboration with West Suffolk Alliance partners, include a range of nursing, therapy, specialist, and ongoing temporary care and rehabilitation, some at our Newmarket Community Hospital.

We do our utmost to achieve outstanding clinical outcomes for patients and our values of fairness, inclusivity, respect, safety and team work guide how we work and behave as a team.

With nearly 5,000 staff, from all over the world, we strive to make our organisation a great place to work. Whatever your role or ambition, we want to help you be the best you can be.

We promote a diverse and inclusive community where everyones voice counts and you can #BeKnown for whoever you are.

Join us. What will you #BeKnown for?

Job description

Job responsibilities

Please see the full job description for more information

Key Tasks & Responsibilities:

Communication

1. Liaise with other internal and external health care professionals / agencies and all professionals involved in the continuity of patient care. Ensuring discharge and transfer takes place in a timely fashion.

2. Act as a resource to ward staff offering advice and help on all aspects of discharge planning, prioritising complex cases.

3. Use appropriate documentation and information technology to ensure that discharge arrangements are documented accurately.

4. Maintain links and communication with community colleagues ensuring they are involved at the earliest opportunity for the discharge of patients with complex needs.

5. Utilise communication skills to ensure patient/relative involvement is central to discharge practice.

6. To facilitate the assessment for patients who would need to undergo the Continuing Health Care Assessment process in the community in accordance with the Trusts policy and in liaison with the CCG, whilst maintaining appropriate standards of documentation.

7. Liaise with the Social Services to enable patients who are self-funding to be supported appropriately and their discharge from hospital is not delayed. Showing some awareness of the process and financial agreements that are required to before discharge.

Planning and Organising

1. Work in partnership as a member of the multidisciplinary team in facilitating discharge planning.

2. Organise and manage workload on a daily basis, taking into consideration the team as a whole, ensuring all clinical areas have SDPT cover in the absence of colleagues.

3. Ensure Transfer of Care information is timely and accurate and available for the validation process.

4. To collect, collate accurate information on Transfers of Care, verifying and validating information with Adult Care Services, in the absence of the Team Lead.

5. Actively participate in MDTs and board rounds where appropriate and facilitate discussion regarding EDD and discharge plans.

6. Provide timely and accurate information regarding patients with Length of Stay greater than 14 days and work closely with colleagues and teams within the Transfer of care hub for those patients who are deemed as medically optimised but remain in an acute bed.

Managing People and Resource

1. Ensure that all working relationships are managed to maximise communication between service users and providers.

2. Promote the principles of inter disciplinary working in order to facilitate effective discharge.

3. Manage and provide guidance and leadership to discharge planning practitioners within the team.

4. Monitor discharge practice within clinical areas and escalate to an appropriate person when there is evidence of a deficit in practice.

5. To ensure all duties are carried out to the highest possible standard in accordance with the Nursing & Midwifery Councils Codes of Professional Conduct.

Training and Teaching

1. When required, working with the Ward managers, assess the learning needs of staff regarding discharge planning.

2. Participate in the setting of standards to monitor and evaluate the discharge process.

3. Actively participate in the audit of discharge and the implementation of successful outcomes to improve the procedure.

4. Undertake training activities as appropriate including induction for new members of staff.

5. Participate in the development of patient information.

6. Ensure appropriate information is available to patients, relatives and carers in order for them to understand the discharge planning process, working in conjunction with other health care professionals.

Research and Development

1. To continuously review own training needs, seeking to develop new skills and knowledge, which contribute to the enhancement of the service.

2. Play an active role in contributing to own personal development.

3. Undertake audit related activities.

Policy and Service Development

1. Contribute to and support service development through involvement in specific project teams providing advice on how to improve the discharge process.

2. Contributing to new initiatives and implementing the same to reduce discharge delays and support identified targets.

3. Constructively contribute to the implementation of change projects supporting others in understanding the need for making agreed changes.

4. Promote adherence to local or national policies, procedures and guidelines.

5. Contribute to effective communication and liaison with the inter-disciplinary team ensuring a unified approach to service development.

Administration

1. Manages time and resources efficiently to provide effective outcomes for the service provision.

2. Facilitate timely completion of NHS Continuing Healthcare documentation.

3. Submits reports as required in a timely fashion.

4. Ensure Trust /Team Policies and Procedures are adhered to.

5. Maintains accurate records of all written work.

Clinical and Professional

1. Act as an advocate for patients when appropriate, ensuring their discharges are safe and effective.

2. Identify, in conjunction with members of the multidisciplinary team, patients who would benefit from intermediate / transitional / rehabilitation services provided by the community and non-acute care provisions within the Trust.

3. Encourage and promote continual quality improvement and implementation of evidence-based practice

4. Act as a role model, providing clinical leadership to all staff, and evaluating programmes of ongoing improvements in relation to discharge planning.

5. Attend and represent the discharge planning team at meetings as required

Governance

1. To ensure service complies with Trust Policies. To monitor and rectify any identified shortfalls in accordance with established procedures.

2. Work within an overall framework of Clinical Governance.

3. Implement Trust Policies such as Risk Assessment and Incident Reporting.

4. To assist in the investigation of and response to complaints in accordance with the Trusts complaints system.

Person Specification

Education and qualifications

Essential

Level 1 registration with the NMC Relevant degree or experience - willingness to work towards degree qualification if already held Evidence of continuing professional development Assessor or mentorship qualification Prep for Mentorship or 998

Desirable

Management qualification

Experience and knowledge

Essential

Experience in complex discharge planning MDT working Ability to offer professional guidance to staff Demonstrates the ability of teaching in the clinical & classroom setting

Desirable

Understanding of the new NHS agenda Involvement in clinical audit initiatives Working knowledge of the NHS Continuing Healthcare and discharge to assess process Experience in a variety of healthcare settings Working knowledge of the Care Act

Skills and abilities

Essential

o Prioritisation and problem-solving skills Ability to influence and enhance patient care Vision for the development of this post Ability to develop positive interpersonal relationships with staff at all levels High professional standards and understanding of professional issues

Personal qualities

Essential

Able to use initiative Able to prioritise workload Good communicator Flexible approach to working hours/duties Positive attitude to change Motivated

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