Community Transfer of Care Hub Case Manager

2 months ago

Warmley, United Kingdom Sirona care & health CIC Full time

Job summary

Are you a nurse or therapist looking for a community job in a developing service?

Are you passionate about supporting people to return to their own homes following acute illness or injury?

UHBW are launching two new Transfer of Care Hubs to support our patients with discharge planning from admission through leaving hospital and into the community: one Hub at the Bristol Site and one at Weston General Hospital. The Transfer of Care Hub will bring together the acute trust, community partners (Sirona), Local Authorities and Voluntary Sector colleagues across BNSSG to create a new team from multidisciplinary backgrounds.

The aim is to work collaboratively to support patients to get Home First by collocating a team of professionals from different organisations to streamline complex discharges.

You will need to have experience working in the community setting and an understanding of the levels of clinical acuity that can be supported in peoples own homes. Alongside this you will have an understanding of rehabilitation pathways, discharge planning and mental capacity issues, excellent interpersonal and negotiation skills.

In return, we will provide you with regular training and supervision and enable you to become involved in future service developments

Main duties of the job

Be a key member of the multi-disciplinary team, responsible for providing person-centred, holistic assessment to facilitate discharge from the acute hospitals to the right discharge pathway. Responsible for triaging referrals received by CToCH. This may include liaising with the patient, family/carers and ward staff to identify the most appropriate discharge pathway. Support the CToCH to discuss complex cases with all partners in the Transfer of Care Hub to agree a joint action and discharge plan. To utilise multi-disciplinary assessment skills, supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment To be able to effectively triage and prioritise a large caseload and be able to adjust daily work plan in response to system-wide pressures and escalation. Pro-actively optimising the usage of community capacity on a daily basis. High level of problem-solving required, gathering information from a range of sources, using professional experience and clinical knowledge to inform decision making. This includes being able to complete mental capacity assessments and make best interest decisions where appropriate.

About us

We are Sirona care & health, a Community Interest Company committed to providing local communities with a range of high-quality specialist healthcare services across Bristol, North Somerset and South Gloucestershire. For us, it's about the personal approach; we take pride in what we do and deliver the high standard of care we would expect for ourselves and our families.

At Sirona, we continue to build an inclusive culture that encourages, supports, and celebrates the diverse voices of colleagues, people and communities. We welcome applications from all who feel they have the skills and attributes to make a real difference.

Benefits:

We offer NHS Agenda for Change Salary, Terms and Conditions and the NHS pension scheme plus much morePlease see the benefits leaflet attached to this advert for details.

We offer NHS Agenda for Change (AfC) salary including annual leave supplement, Stakeholder pension, a range of health and wellbeing incentives, high street discounts, plus much more

Job description

Job responsibilities

Please see the job description and person specification attached for further information on the role.

We are unable to provide sponsorship for this role and can only accept applications from UK based applicants.

Person Specification

Qualifications

Essential

Professional Qualification in Nursing, Occupational Therapy or Physiotherapy. Registered with NMC, HCPC or RCN

Skills, knowledge and experience

Essential

Able to work across professional and organisational boundaries recognising when there are barriers to partnership working and able to implement solutions to overcome these The ability to interpret clinical information, use analytical and problem-solving skills to inform decision making Able to demonstrate innovative practice Ability to coordinate and manage a caseload including prioritising the workload, appropriate use of escalation plan, time management and delegation. When required to be able to present information to the CCG to support the requirement of additional funding (, 1-1 support) to enable a hospital discharge Ability to complete mental capacity assessments when required and if the patient lacks capacity act as the lead for making a best interest decision as part of a multi-disciplinary team A competent level of IT skills including user knowledge of core Microsoft Office packages and electronic patient records

Desirable

Ability to present self and service in a professional manner promoting the service at all times Experience of working within hospital and community settings Ability to build, and maintain, effective working relationships at all levels

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