Complex case manager

To actively facilitate effective and timely discharge of patients through liaison with appropriate departments, organisations, and professionals. Attended the daily ward board rounds of patients on your case load to review patients needs related to discharge and update the ward MDT. Provide Specialist Knowledge, support, and guidance to colleagues regarding discharge planning and mental capacity. Demonstrable working knowledge and practical application of legislation relevant to discharge and transfer of care process including the Care Act. Have extensive knowledge of health and social care services, roles and responsibilities and apply this to support patient discharges. Liaise with Site Manager to ensure complex discharges are expedite on date of discharge. To Coordinate / Participate in family, professional, and best interest meetings with multi-agencies to discuss Patients discharge arrangements. Identify delays in the patient journey and act appropriately to challenge process. Expert knowledge and understanding of the D2A model and pathways Be the health lead in understanding the appropriate Discharge to Assess (D2A) pathway appropriate for patients and be ready to facilitate this pathway as soon as the patient is medically optimised. Responsible for the integrated discharge hub and ensuring patient referrals are forwarded to relevant agencies in a timely manner Responsible for updating Transfer of Care form (TOC) post IDT Hub with pertinent information identified to support Patients needs for a pathway to be agreed. Work collaboratively with Specialist Teams internal and external to confirm clinical plans in place to reduce non valued added in-patient days and follow-on care post discharge. Liaise with General Practitioners, community nurses, clinical support professionals and other agencies to facilitate a patient discharge. Liaise with the community hospitals to ensure the continuity of patient care, when crossing healthcare boundaries. Act as a focus for investigations and resolution of individual patient discharge problems, utilising the links with other professionals and an overall knowledge of available facilities and options for patient care within the community. Support wards to diffuse and deal with conflict and delicate discharge situations to agree a discharge plan. Please see the attached job description for full role responsibilities

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