Improve and develop known process for referrals and assessments and work within agreed assessment formats with adherence to established pathways. The post holder will need to use their extensive skills and experience for assessing and interpreting acute and other patient/client conditions with recommendations for appropriate discharge processes. Undertake assessments and re-assessments of hospitalised residents on behalf of Care Home providers according to agreed criteria. This will require the post holder to have specialist knowledge across a range of conditions, procedures, local systems, and underpinned theory of them. Liaising with the wards to confirm the requirements for discharge, including any documentation and medication needs where required. Liaise with Care Homes, Discharge Liaison, Discharge Support Teams and Brokerage about the discharge arrangements to streamline the process and ensure the best possible outcomes for vulnerable people are achieved. This will include providing and receiving complex, sensitive information daily for many patients. Liaise with District Nurses and other Specialist Nurses to support person centered care planning, where required. The post holder will therefore need to assimilate complex facts or situations requiring a comparison of range of options for the patient. Ensure that, wherever possible the views and needs of older people within the Care Home setting are sought and represented with due regard to the persons mental capacity and undertake Mental Capacity Assessments where required Report on issues raised by Care Homes about quality of discharge, working closely with Discharge Teams, the Continuing Healthcare Team, the Care Homes Forum, the Ageing Well Working Group, Councils Contracts & Brokerage Team and future groups that may be developed to support this work stream. Provide support to Care Home and hospital staff relating to admission and discharge processes. Post holder to identify training needs and or requirements and support with arranging training to be completed prior to Care home admission. Will provide clinical supervision to other staff and students, in addition to mentoring support for Care Home staff (which will also include on a one-to-one basis), where appropriate. Act as a point of contact for ward staff/MDT/Care Homes, when residents are admitted to hospital from Care Home settings to monitor progress and keep on-going communications. Work in partnership with Care Home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues. Provide data for monthly reporting as agreed. Produce monthly monitoring reports, including case studies for submission within quarterly reports, and develop Key Performance Indicators relevant to the role. Support other areas of work at times, which may include supporting flow and end of life pathways, Continuing Healthcare Checklists, Nursing Needs Assessments (HANNA), Discharge to Assess referrals, training, education, performance improvement and support, safeguarding enquiries, health promotion. Work closely with the GWH Hospital Discharge team to resolve difficult or delayed discharges, especially on challenging situations where parties may not agree. The post holder will also be required to plan and organise activities that will enable delivery of the service e.g. discharge support and coordination. Facilitate the continuation of the development of and implementation of best practice within the Care Home community. Assist in developing effective links and communication between Care Homes, other care services and the wider community to deliver a seamless service for clients and staff in the Care Homes. Support the daily integrated flow meetings, multi-disciplinary team meetings and best interest meetings to expedite discharge wherever possible and to raise any issues or concerns that may be delaying a discharge.