Integrated Discharge Coordinator
Job Description
Job summary
The Discharge Coordinator plays a pivotal role in ensuring the safe, timely, and effective discharge of patients from hospital. Working as part of the multidisciplinary team, the post holder will coordinate complex discharge plans, facilitate communication between health and social care professionals, and work closely with patients, families, carers, and external agencies to support seamless transitions of care.
The post holder will proactively identify and address barriers to discharge, ensuring that patients receive the appropriate support and services required upon leaving hospital. They will provide specialist advice on discharge processes, contribute to improving patient flow, and support the delivery of high-quality, patient-centred care.
The Discharge Coordinator will work collaboratively across acute, community, and social care settings to ensure compliance with national guidance, local policies, and best practice standards, promoting positive patient outcomes and reducing unnecessary delays in discharge.
We are particularly interested in candidates who have experience of undertaking NHS Continuing Healthcare (CHC) Nurse Assessments.
Main duties of the job
To coordinate complex patient discharges by liaising across the Health and Social Care economy and working collaboratively with Primary Care and third sector services, This is an integral role provided at both the acute sector and the community setting. The purpose is to assist the Trust to maintain capacity and flow throughout the whole system and to promote safe and timely discharges, with the intent to reduce the detrimental outcomes associated for patients who have a prolonged length of stay.
The Trust have a number of discharge initiatives that aim to bring care closer to home, therefore the post holder must be confident and proactive in sensitively challenging conventional thinking.
About us
Come and join a Trust rated Outstanding by the CQC. South Warwickshire University NHS Foundation Trust have been rated as outstanding following our latest inspection by the CQC and we are recruiting new staff to come and help us improve even further. In addition our staff survey results have placed us 4th in the country for recommended place to work.
We provide services across Warwickshire and beyond ranging from Hospitals in Warwick, Stratford-Upon-Avon, Royal Leamington Spa and Shipston-on Stour to Community Services across the county. We are a progressive, expanding organisation with great ambition around improving quality, integrating pathways and delivering high levels of productivity.Our values can be summed up in one sentence. We are 'Trusted to provide safe, inclusive, effective and compassionate care'. Throughout the recruitment process you will be asked to think about how you demonstrate these values and how they impact on your work. It doesn't matter what role you do, whether it is patient facing or not, we are all working in the same way with our values at the core.
As part of our commitment to Equality, Diversity and Inclusion we encourage all applicants to complete a short survey. This can be accessed via the link below:
https://forms.office.com/e/ahWY3eAGM2
We appreciate you completing the survey.
Job responsibilities
Work independently managing own allocated case load.
To respond to referrals within 1 working day, notifying Discharge Team Manager/ Leader immediately should this not be achievable.
To work towards the specified Estimated Discharge Date (EDD) identified by the Clinical/ Multidisciplinary Team.
Review daily, each complex patients progress towards discharge to determine if the plan needs to be revised and actioned in order to achieve a timely and safe discharge.
To prepare complex patients and their relatives at the earliest opportunity in relation to planning for discharge ensuring the philosophy of assessments taking place closer to home is reiterated rather than in the hospital setting.
To support ward staff and assist in coordinating patient discharge for those entering end of life, liaising with necessary partners and organisations such as Continuing Health Care, local hospices, District Nurses, Voluntary sector and Charitable organisations.
Ensure the discharge database is accurately completed and up-dated to enable Delayed Transfers of Care patients and the reason why they are delayed to be identified and counted on a daily basis.
To identify appropriate patients through the trusted assessment process to the various Discharge to Assess initiatives to bring care closer to home for patients.
To undertake Mental Capacity assessments in accordance with the Mental Capacity Act (2005) in relation to specific decisions pertinent to the patients discharge plan.
To lead and coordinate the NHS Continuing Health Care process in accordance with The National Framework for CHC and based on the trusted assessment agreed with SWCCG.
To inform and provide the Team Manager/ Leader with all data required to prepare the weekly SITREP report on Delayed Discharges in accordance with the Care Act (2014).
To escalate to the Team Manager/ Leader patients declining to leave an acute or community bed will require choice directive.
To undertake or deputise for some aspects of the Team Leaders role when necessary, such as attending meetings.
To cover and rotate through all areas as allocated by the Team Manager/ Leader including Acute, Community sectors and the D2A care homes.
To participate in the delivery of new Trust initiatives related to the process of patient discharge.
Liaise closely with all the Infection Control and Risk Management Teams to minimise any risk to patients in the transfer / discharge process.
Respond to all verbal and written complaints in line with the Trust complaints procedure initiating resolutions where possible and report outcome to Discharge Team Manager/ Leader.
Ensure adherence to all measures stipulated in the Trusts in patient Discharge Procedure and other policies related to the discharge process.
Knowledge, Skills and Experience Required
To have a full understanding of the Discharge Process and the knowledge and skills to apply effectively in practice to ensure a safe and timely patient discharge takes place.
To assist in identifying, negotiating and co-ordinating the movement of patients who are suitable to transfer to other health or social care facilities.
To promote integrated and collaborative working with health, social care teams and third sector providers.
To initiate and lead patient case conferences or best interest meetings, as necessary with discussions and actions documented.
The post holder will be required to use a computer, either stands alone or as part of a networked system and will be responsible for the quality of information recorded.
To sensitively challenge conventional thinking that hinders or creates a delay in the process of patient discharge.
Measurable Results Areas
The post holder will maintain accurate records both written and electronic, deal with highly sensitive information respecting confidentiality and security at all times in accordance with Trust policies and data protection.
To support and actively participate in audits pertaining to patient discharge and whole system flow.
To contribute to the development of standards, protocols, care pathways and clinical audit when requested.
To contribute to strategies and use relevant information systems to collect and interpret data that will lead to the formulation of action plans that seek to improve the discharge process.
Communications and Working Relationships
To utilise information systems, internet, hospital intranet and results reporting to facilitate the discharge process.
To ensure the discharge database is accurately up-dated, to capture all complex patients.
To attend designated multidisciplinary meetings to agree, set goals and action accordingly within a specified time scale.
To communicate with staff, patients, carers and relatives using a professional and sensitive manner to respond to a range of enquiries maintaining confidentiality at all times.
To involve the patient, relatives and carers offering information, literature, advice and guidance; keeping them fully informed of the discharge process and plan.
Ensure external communication links with all relevant stakeholders is established and maintained, by accurate information sharing with all social care & health community teams, General Practitioners and third sector organisations, such as Age UK.
Education and Training
To support the Discharge Team Manager/ Leader in assisting newly appointed team members to achieve understanding and competence in the art of Complex Discharge planning.
To provide support, education and training to nursing staff, including the induction of new staff and other multidisciplinary workers in all aspects of discharge planning.
Promote an environment through education ...
