Primary Duties and Areas of Responsibility Support MDT to work in accordance to current Torbay and South Devon NHS Foundation Trust/Devon Discharge policies Identify through use of appropriate IT systems (Paris, Care First etc), medical notes, liaising with patients and/or carers relevant health and social care history including any existing services and which authority (Torbay and South Devon NHS Foundation Trust/Devon Partnership Trust/Devon County) is responsible for care provision Having gained informed consent from the patient and/or carer share relevant information with wider MDT to facilitate appropriate care and discharge planning. Screen all patients on the ward and with the wider MDT identify those patients likely to require ongoing health and social care support including care or support services Assimilate appropriate information from hospital stay; input re-referrals directly onto Paris in a timely manner or onwards referrals to the Discharge Hub. Maintain regular contact throughout hospital stay with Zone teams, specialist teams, Hospital Assessment and Discharge Team and Care Direct Plus/Devon Hospital Discharge Team ensuring all those involved in the ongoing care of the patient and/or their carer are aware of discharge planning processes, throughout hospital stay and at the point of discharge Ensure all those involved in the current or onward care of the patient carry-out their assessments and related activities in a timely manner; this will involve negotiation with and constructive challenge of other professionals including doctors, nurses and the wider MDT This will include OT assessments recording and requesting of drugs to take away (TTAs) Support ward clerk in ensuring that transport has been arranged for the patients discharge as appropriate Meet with consultants/junior doctors regularly to obtain medically appropriate estimated dates of discharge (EDDs); liaise with the wider MDT to ensure EDD set take into account the holistic needs of the patient Support the ward clerk in ensuring EDDs are recorded and updated on Swiftplus. Meet regularly with ward manager and wider MDT to ensure clinical delays are appropriately identified, recorded and reported in line with legislation and local policy Support nursing and medical staff in ensuring that the patient and their carer/families are aware of EDD, particularly if it changes during the episode of care.
Support medical and nursing staff to ensure that patients and their families/carers are fully involved in discharge planning and are aware of all plans Negotiate with patient, carers/families and MDT where there is disagreement about appropriate discharge date or other plans for discharge. Co-ordinate arrangements for case conferences or multi-professional meetings where discharge plans are complex or there is dispute Prepare and co-ordinate patient information for weekly multi-disciplinary (MDT) meeting where they occur; ensure all relevant information is available and presented at the meeting. To participate in an Discharge Co-ordinator duty rota for weekend cover Maintain the overview of discharge planning arrangements for all patients on the ward; act as central point or contact for patients, carers, families, other professionals and specialist teams and the ward-based MDT with regards to issues relating to discharge Carry out baseline assessments, record those assessments and request simple services or alterations to packages of care for Torbay and South Devon NHS Foundation Trust service users within the Paris IT system. Ensure appropriate and timely hand over to Zone team for review and follow-up at the point of discharge Liaise with Care Direct plus and the Devon Hospital Discharge Team regarding the outcome of MDT assessments and care requirements for patients based on the outcomes of those assessments To contribute to detailed care plans/summary of needs and setting of patient centred goals and objectives based on initial assessments carried out by the multi-disciplinary team and contributed to by the post holder.
To ensure all recorded information is accurate, up-to-date and factual Work closely with Hospital Assessment and Discharge Team and Discharge Liaison Nurses to ensure that patients, their families and carers have access to appropriate and timely information about Torbay and South Devon NHS Foundation Trust policies and processes including financial assessment; ensure that patients families and carers are appropriately supported whilst looking for suitable placements and/or care and are aware of timescales within legislation and local policy To develop an understanding and awareness of all the resources available to meet the needs of people in the community and to contribute to the assessment of patients and/or their families/carers identifying which resource can best meet their needs Make onward referrals as appropriate to specialist teams or resources such as the Financial Assessment and Benefits (FAB) Team, Intermediate Care or Mental Health teams and where appropriate highlight the need for carers assessments. Support the collation of any relevant statistical information as required by Torbay and South Devon NHS Foundation Trust or Devon Partnership Trust which will help with developing or improving services for patients and/or carers Assist with patient or public involvement activity (PPI) as required such as follow-up phone calls or patient satisfaction questionnaires Ensure any risks highlighted during the patients stay are recorded appropriately and identified to relevant individuals to ensure that risk can avoided or minimised where possible and that staff, the public or other agencies are not put at unnecessary risk. To work autonomously continually prioritising incoming work based on individuals needs. To manage workload in a manner that is not detrimental to other colleagues and targets To carry out any other duties commensurate with the grade of the post as may be assigned by the project lead from time to time To work flexibly support and contribute to new ways of working to ensure continuous service improvement and development Policy and Service Responsibility Where safeguarding adults concerns are raised ensure that concerns are reported in accordance with legislation and policy To work in adherence with policies and procedures of Torbay and South Devon NHS Foundation Trust and where acting on their behalf in accordance with policies of partner organisations (Devon Partnership Trust/Devon County); to include health and safety, confidentiality and data protection policies Responsibility for Supervision, Leadership and Management To be responsible for own continuing professional development including participating in supervision and achievement review and undertaking training as required Contribute to the training and development of new staff or staff new to the role to ensure the continuation of good practice
