To act as a core member of the Complex Discharge/ Specialist Palliative Care multidisciplinary team. To facilitate sensitive communication including conversations about Advance Care Planning, End of Life Care and Preferred Place of Care / Place of Death with patients and those close to them. To facilitate the effective management of patients referred to the team for discharge planning, ensuring their experience is seamless and of high quality. To demonstrate high levels of autonomy as well as the ability to work as part of a team. To work proactively to ensure patients are able to be discharged to the place of their choice where possible. Arranging packages of care for patients at the end of life, tailored to the needs of individual patients and clinical need. In addition, be able to recognise any potential limitations or risk and always act to prioritising and safeguard the patients needs. Providing a central point for professionals to access current information regarding packages of care and liaise accordingly for access and provision of essential equipment required for safe and effective care at home. In collaboration with members of the multidisciplinary team, assess the needs of the patients, families and those important to them and provide specific advice or support as appropriate. To demonstrate effective communication skills when discussing complex and emotive clinical situations with all levels of staff. Promote the use of approved End of Life Care tools and process within the Trust including the Individual Care Plans for Dying People, Advance Care Plan. Contribute to the monitoring and evaluation of End of Life Care tools and processes. To work collaboratively with both hospital staff and community teams to ensure consistent and up to date communication to facilitate both written and verbal handover of patient information to the appropriate key worker and ensure continuity of care. Maintain accurate and concise documentation and provide accurate and detailed records to support Trust quality metrics and other audit/evaluation activities. Management of the discharge process and data collection to demonstrate: Increase number of patients achieving their preferred place of care Increase number of patients dying at home Reduction in the number of expected hospital deaths Reduction in the length of hospital stay in the last eight weeks of life by supporting patients to be discharged improve coordination of discharge and transfer from hospital to community. Improve provision of home care packages for patients with palliative care needs. Improve communication between healthcare professionals caring for rapidly deteriorating patients in the last weeks of life. Increased patient and carer satisfaction.