Job Purpose
The focus of the Complex Discharge Service is to support the timely identification, assessment, and support for discharge to the most vulnerable patients in the Royal Surrey. The Complex Discharge Service supports the identification and planning of complex discharge in addition to ensuring patients are transferred to the most appropriate care setting in a timely manner whilst providing a safe, effective, and positive patient experience. The principal responsibilities of this team are:
1. To provide clinical expertise and decision-making for timely effective discharge and the management of patients admitted from care homes.
2. To provide clinical expertise and decision-making for timely effective discharge and the management of patients referred to the Complex Discharge Service.
3. Work with the Team Lead and provide support to the Complex Discharge Coordinators, providing guidance and oversight to ensure high standards of care and service delivery.
4. Conduct and oversee mental capacity assessments to determine patients' ability to make informed decisions about their care.
5. Make and support best interest decisions for patients who lack capacity, ensuring their needs and preferences are prioritized.
6. Act as the primary point of contact between the hospital, care providers, and community services to ensure coordinated and continuous care.
Job Summary
1. To work with the team lead to prioritize and allocate workload on a daily basis, liaising with other teams as required to identify new patients admitted or referrals.
2. To assess all newly admitted patients within allocated workload to devise a Transfer of Care management plan. This will involve understanding the patient’s current condition and previous level of functioning. Information will be obtained from families/carers, GPs, Community Providers, Social Care, and other relevant providers to identify and address issues early that may impact on a timely transfer of care.
3. To have an in-depth knowledge of all aspects of care and discharge pathways and utilize holistic knowledge and expertise to assist in leading the MDT to support timely discharge.
4. To ensure the patient and family are informed on admission about the transfer of care process and agree and negotiate how they will be involved throughout the patient journey.
5. To be the point of contact for patients/families, care homes, and carers for issues relating to transfers of care and identifying concerns or potential complaints early.
Royal Surrey is a compassionate and collaborative acute and community Trust. Recognizing that our 5000 colleagues are our greatest strength, we offer a comprehensive health and wellbeing program along with a commitment to developing and advancing your career. Our diverse and welcoming Royal Surrey family will ensure you feel valued from your initial interview through your entire tenure.
We are clinically led and provide joined-up care by bridging the gap between hospital and community services alongside regional specialist cancer care. Our main acute hospital site is in Guildford with community hospital sites at Milford, Haslemere, and Cranleigh. We provide adult community health services in homes across Guildford and Waverley.
The Care Quality Commission (CQC) has given us an overall rating of Outstanding.
Royal Surrey has a strong reputation and history to build on. We are proud of our achievements and we are investing in our colleagues through our commitment to supporting professional development as well as investing more than £45 million in our physical environment and new equipment in the next few years. There has never been a better time to join us.
Although it isn't the Trust's normal practice, adverts may close early, so you are encouraged to submit an application as soon as possible.
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For further details / informal visits contact:
Name: Sarah Holbrook
Job title: Lead Nurse for Patient Flow
Email address: sarah.holbrook1@nhs.net #J-18808-Ljbffr