Discharge Navigation Lead - Physiotherapist/ Occupational Therapist/ Nurse
The Transfer of Care Hub at the Royal London Hospital consists of staff from East London Foundation Trust, London Borough of Tower Hamlets and Barts Health NHS Trust working in partnership to facilitate timely discharge of patients from hospital. The team consists of nurses, therapists, social workers discharge navigators and admin support staff.
The role requires advanced clinical/ discharge navigation skills in patient case management to ensure that patients are transferred safely to the appropriate community setting. The individual will have experience and knowledge of discharge practices, including Discharge to Assess, and of community services in order to identify and facilitate discharge and prevent unnecessary hospital readmission. The post holder will work to develop and maintain relationships with other key stakeholders and system partners including acute staff, local authority colleagues, voluntary agencies and the clinical commissioning group.
See attached JD
The Transfer of Care Hub staff screen all referrals received and liaise with the wards and hubs in other boroughs, creating a seamless and timely care pathway. The post holder will provide a specialist source of expertise in decision making and demonstrate a passion for excellent quality, person centred care and work creatively in order to achieve the best possible outcomes for our service users. The post holder will demonstrate a dynamic approach for complex patients to ensure that community services and other key stakeholder resources are used holistically and appropriately.
The post holder will work collaboratively with secondary care to create bespoke and coordinated plans to support discharge and coordination of services and will be responsible for providing an urgent response to requests for assessment, alongside proactively case managing individuals until they are discharged from hospital.
Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive – so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.
Main Duties and Responsibilities
Clinical
Within the limitations of the Hospital Discharge Service: Policy and Operating Model, to ensure that patients and their families/carers are consulted and encouraged to be part of the discharge planning process.
To proactively co-ordinate, review, case manage and facilitate discharges into community services as part of the Transfer of Care Hub.
To demonstrate expert and specialised knowledge of community services in order to plan discharge; undertaking assessments e.g. for equipment, as appropriate.
To demonstrate knowledge of complex clinical presentations and develop evidence based recommendations and advice regarding discharge pathways for patients.
To be able to analyse multiagency records and information.
To be aware of professional boundaries and the need to access expert and specialist opinions when required.
To be able to participate in client feedback and case discussions.
To be able to identify clinical risks and escalate appropriately.
To maintain safeguarding knowledge and ensure risk assessment and threshold issues are addressed and escalated appropriately.
Management
To triage referrals received from the acute trust promptly and delegate responsibilities to other members of the TCH.
To work flexibly within the Transfer of Care hub, advising on out of borough referrals as well as those for Tower Hamlets residents.
To be accountable for safe and evidenced based advice and delegation of work.
To be able to demonstrate the use of enhanced telephone assessment and triage skills.
To produce reports and daily statistics on TCH performance and to support the service to meet targets and performance criteria.
To be able to escalate any areas of practice or service concerns to Transfer of Care Hub Team Lead.
To be accountable for own work and that of other staff within the Team and within broad service specifications.
To be able to lead the planning and organisation of triage and screening hub processes, ensuring a 7 day 8am-8pm rota is covered .
To be able to effectively manage and prioritise own caseload and delegate to junior staff accordingly.
To be able to participate in/ lead working groups for service development, audit, protocol and clinical policy development.
To be able to participate and contribute in team meetings, supervision, and reflection.
To be able ensure cover arrangements for sickness and annual leave and escalate any issues to the Clinical Lead or Lead Clinician.
To contribute to quantitative or qualitative audit work including reports and presentations.
To be adaptable and/ or skilled in setting up new processes and projects.
Communication and Relationships
To communicate effectively and work collaboratively with colleagues within the Royal London Hospital, social services, community and voluntary sector services to ensure the delivery of a coordinated multidisciplinary discharge service.
To be able to communicate highly complex, sensitive information where agreement and cooperation is required.
To frequently throughout the day utilise formal and informal communication mechanisms including telephone, face-to-face, written and electronic, to a wide variety of staff and people within and outside the service, discussing both clinical and non-clinical information to ensure effective communication is maintained.
Use advanced and innovative interpersonal skills of negotiation, persuasion and conflict resolution when appropriate. This may include challenging perceptions when appropriate and assisting practitioners to challenge in stressful situations.
To constantly present issues in a professional manner suited to the intended audience.
To be able to effectively interpret needs in a multi-agency context where other agency criteria and issues of consent and confidentiality may require sensitivity and challenge.
To be able to effectively communicate the needs identified through assessment by the referrer to practitioners and care providers.
To be able to network widely and access wide ranging services to coordinate effective discharge planning.
To frequently, on a daily basis use verbal and non-verbal communication to receive and disseminate complex and confidential clinical information, that may be distressing, in all therapeutic, educational and professional contexts acknowledging sensitivity and utilising approaches appropriate to the complexity of the context or culture.
To actively develop relationships with all levels of professionals in acute and community health and social care organisations, to gain an understanding of roles, promote effective communication and collaborative working to ensure best outcomes for patients and their carers.
To regularly chair an MDT call between partners involved in discharging patients from the Royal London Hospital (RLH), ensuring barriers to discharge are identified and actions to address these are agreed and are followed up.
Maintain confidentiality consistent with Trust and service policies.
To maintain and develop professional communication links across health, social care and voluntary sector including representing the service and or profession at multidisciplinary collaborative forums and networks. To support the staff you supervise in doing likewise.
Use tact and diplomacy to provide and communicate complex, sensitive information where motivational, negotiating, empathetic and reassurance skills are needed.
Keyrelationships:
Liaises directly and effectively with the following:
o Transfer of Care Hub staff
o Hospital Social Work Teams
o Consultants and junior doctors
o In-Reach nurses
o Reablement service
o Clinical nurse specialists, ward nurses/managers
o Ward staff in various specialities within RLH and other referring hospitals
o Community therapy teams
o Discharge Services/Hubs in other boroughs
o Community nursing teams
o Patients and their families
Analytical and Judgemental
Be able to quickly interpret and understand complex information relating to services and patient care and be able to make autonomous decisions where there is no clear answer.
Ensure that all work is stored correctly on the shared drives and accessible to all relevant staff and senior managers though well organised systems and processes.
Undertake audit as and when required to support service quality and development.
Be aware of and participate in risk assessment for the benefit of self, colleagues and clients, in line with the Risk Management Policy and Health & Safety at Work Act 1974.
Planning & Organisation
Identify areas of concern in service delivery and escalate these to the senior management team in a timely manner.
Be aware of the organisation’s objectives and ensure services are delivered in line with these.
Ensure all necessary and relevant data is captured and reported as required.
Organise and prioritise own workload, and delegate to junior staff within agreed timescales building in flexibility to deal with unforeseen demands on time and resources.
Assist in monitoring and maintaining standards and take appropriate corrective action as necessary.
Human Resources
Manage staff in accordance with the relevant ELFT policies and procedures.
Monitor and manage performance, disciplinary and sickness issues in accordance with ELFT policies and procedures.
Participate in the recruitment and selection of staff for the IDH when vacancies arise in accordance with Trust policies and procedures.
Ensure all new staff have a robust induction programme.
Take responsibility for your own continuous professional development, maintaining a sound level of professional knowledge and competence in line with the Personal Development Plan agreed at annual appraisal.
Ensure attendance at all mandatory and core training, ensuring staff take responsibility for compliance with the training policy.
Effectively manage staff, ensuring supervision and appraisal for staff is implemented according to Trust policy and quality is regularly audited.
Information Resources
Manage and monitor systems to ensure team members maintain accurate and contemporaneous records in accordance with ELFT policy and national and professional guidelines.
Ensure that Caldecott principles and clinical governance guidelines are adhered to, including information that may be required for safeguarding and promoting the welfare of adults, audit or research purposes adhering to policies and procedures.
Utilise a range of communication methods with colleagues and managers to include MS Teams, Outlook and other methods of electronic communication
Freedom to Act
Be an autonomous practitioner who is able to use own experience and skills to enhance the quality of community services
Challenge peers and other staff when it is necessary and in the best interests of patients and carers and the organisation
Job Description Agreement
This job description is intended as a guide to the main duties of the post and is not intended to be a prescriptive document. Duties and base of work may change to meet the needs of the service or because of the introduction of new technology. This job description may be reviewed from time to time and changed, after consultation with the post holder.
This advert closes on Tuesday 4 Feb 2025