Transition Care Coordinator

2 weeks ago


Watford, United Kingdom Hertfordshire Community NHS Trust Full time

Job summary

Are you passionate about making a difference to the lives of young people with complex health needs? Would you be interested in working with those aged 14-21 years through their transition into adulthood?

Main duties of the job

The Hertfordshire Young People's Health Transitional Service supports young people aged 14-21 years, with complex physical health needs and/or life limiting conditions. The role of Transition Care Coordinator is to support and co-ordinate the transition from Children's to Adult Health role includes participation in collaborative working across health, social care and the third sector for transition planning, supporting patients and their families to navigate the patient pathway thereby reducing any delays for the patient and has a large educational component educating bothChildren's and Adult Services to facilitate the transition process.

About us

A big thank you for considering joining us at Hertfordshire Community NHS Trust. You'll find it a great place to work with many benefits offered to you as a member of our staff. We put our patients, their families and carers at the centre of our vision - Outstanding Services and Healthier staff are proud to be Innovative, Caring and Agile in their work to help achieve the Trust vision. We welcome diversity in our workforce and are interested in applicants from all backgrounds and ages. We don't want you to miss out so we'd like you to know that if we have a high level of interest in this role, the vacancy may close prior to the advertised closing date, so please make your application as soon as possible. You've made a great decision to apply to join to HCT - we're looking forward to taking the next steps of the journey with you - APPLY NOW.

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Job description

Job responsibilities

To support and coordinate the transition of care for young people, aged 14-21 years with complex physical or life limiting conditions across Hertfordshire. To enable young people with complex healthcare needs to make a smooth transition into adult care services by ensuring strategic planning of all their care needs with the support of the team lead. Develop relationships with young people and their families making comprehensive assessments of their health and social care needs. To communicate effectively at all times to ensure young people and their families are aware of pathway progression and any delays in the process. To ensure that the young persons voice is central to decision making and that mental capacity is assumed unless assessed otherwise. Act as an advocate for young people during the transition process. Promote self-management of long-term conditions where the young person has capacity to achieve this. To ensure the dignity and respect of the patient is maintained at all times, supporting the Trusts vision and values. To take a key worker role for young people and collaborate with professionals from both Childrens and Adult Services in health, social services, education, and other relevant agencies both locally and at tertiary centres to ensure planned referrals are made to the appropriate adult provider, in advance of discharge from relevant Childrens Service andto ensure unmet needs are resolved and effective transition planning takes place. To have an understanding of the provision and pathways for childrens and adults health, social care, education, and voluntary sector services, to enable effective provision of information and signposting to young people, parents and carers, and other relevant stakeholders throughout the transition period. To network with schools and childrens services in order to provide information for young people and families, and those who support them, on the scope and focus of adult services to manage expectations that arise in service provision during transition. To highlight training needs of the adult receiving services so that they can be addressed during the transition process. To have an awareness of the SEND reform and EHCP process. To support and educate young people and families in navigating health, social care, and education systems through the provision of face-to-face information and personalised support ensuring parents/carers have the information they need about a child, young persons and familys social care support needs and available services, in a format which they find useful and using a range of communication styles. To work as part of the multidisciplinary team, ensuring effective communication across all partners, ensuring that patient confidentiality is maintained at all times. To ensure other agencies are updated on pathway progress on a regular basis and/or when a change has occurred. To track delays and report to appropriate professional. To ensure that safeguarding children and safeguarding vulnerable adult principles are adhered to at all times throughout the transition process for all young people and are reflected in pathway and service development. To act as an appropriate and effective role model at all times. To undertake and/or assist with audits required. Organise own specialist workload, planning activities around the needs of individuals and adjusting daily diary according to priorities as they arise. Maintain high standard of clinical records on SystmOne, ensuring all activity, both direct and indirect patient contact, is recorded accurately throughout the transition process, ensuring all supporting documents are scanned onto SystmOne on behalf of other services.

Person Specification

Qualifications & Training

Essential

Sound knowledge of health and social care services and issues, acquired through training and experience to NVQ level 3 or equivalent knowledge and experience to diploma level

Experience and knowledge

Essential

Experience of working with young people with disability/complex needs and their parents/carers Experience of working within community services, voluntary or statutory organisations Sound knowledge of mental capacity and deputyship

Skills

Essential

Good interpersonal/communication skills including listening, observation, and empathy Good time management and organisation skills Able to work independently and as part of a team Demonstrable IT Skills to include excel, word and creating presentations

Personal Qualities

Essential

Hold a full valid UK licence and have full use of a car
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