The Patient Key Worker role will primarily focus on providing a smooth discharge plan for each patient. The primary function of this role is to ensure patients and relatives are aware of the plan both in terms of interventions and expectations on discharge. Also to highlight to all concerned, any problems that may become apparent that could affect a delay in discharge.
The post holder will facilitate the discharge pathway from admission, liaise with the wider multi-disciplinary team to ensure timely interventions are addressed along said pathway, and provide daily updates to the ward, flow team, and discharge team.
The post holder will also act as a conduit between the ward-based team and the discharge teams and in doing so will provide an extension of the discharge team based within the ward environment. The post holder will also be expected to attend weekly Multi-Disciplinary Team (MDT) meetings with the discharge team and weekly MDT on the allocated ward and length of stay meetings.
Duties will include:
1. To ensure quality care and support service which enables patients to be supported throughout their care pathway whilst promoting independence and protecting choice, dignity, privacy, and safety.
2. To work in support of qualified staff and allied health care professionals in the assessment, planning, implementing, and evaluation of the discharge pathways in conjunction with the discharge team.
3. To assist the wider MDT in facilitating a safe and timely transfer out of the hospital environment for all ward patients.
4. To ensure early conversations are initiated with the patient/carer to ensure the following:
1. Patient and/or carer is aware of the expected date of discharge and is kept informed when this changes.
2. Identifying and escalating any barriers to the patient returning home/care home on the expected date of discharge.
3. Liaise with care agencies/care homes to clarify what the patients’ needs and capabilities were prior to admission.
4. Managing patient and family expectations about discharge destinations within the capability of partner agencies.
5. Attend daily board rounds prompting for EDD and CDD updates.
6. Seek advice from the discharge team at the earliest opportunity if a complex need is identified.
7. Any other requirements deemed appropriate by line manager commensurate to grade.
5. To communicate effectively at all times within the team, other health care professionals, and with the patient family, carers/visitors.
6. To fully participate in the inter-professional evaluation of care, to ensure patients meet their ongoing health & wellbeing needs, focusing on safe and effective discharge/transfer out of the acute hospital.
7. Ensure the initiation of DOLs and MCA at the earliest opportunity in conjunction with the nurse in charge and that restricted interventions appropriateness is discussed daily at board round.
8. To promote comfort and well-being by ensuring that patients' personal and social needs are met and be able to care for a patient's nursing needs to include: vital signs, continence care, pressure area care, wound care, nutrition, hydration, foot care, skin integrity, and mood identification.
9. To identify and report changes in patient’s condition, thus enabling appropriate action to be taken as directed by the multidisciplinary team.
10. Demonstrate safe and effective skills in helping patients to eat and drink; to ensure nutritional needs are met in the most suitable manner.
11. Adhere to Trust and service guidelines regarding the moving, handling, and positioning of patients as laid down in mandatory training sessions, to ensure the safety of self, patients, carers, and colleagues.
12. Demonstrate understanding and practice of optimum Infection Control practice as laid down in training sessions, to ensure safety of patients and colleagues.
13. Maintain accurate and timely records of care using appropriate documentation/electronic devices according to local and Trust standards.
This advert closes on Sunday 15 Dec 2024.
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