Patient Progress Chaser - Community Recovery Service

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Key Tasks and Responsibilities

To work in accordance with the Trust’s policies and procedures. 

To develop a thorough knowledge of the Trust, pathway 1 discharge offer, CRS service and wider community services. 

To provide excellent customer care, demonstrating empathy, patience and a holistic approach to patient care, with commitment to follow-through of care plans and building effective working relationships.

To have excellent communication skills, with the ability to communicate both verbally and written with a wide range of providers, including patients, carers, voluntary, social, primary and other secondary care providers.

To be able to carry out audit of own activities, produce reports and give presentations within the organisation.

To produce reports as required.

To review, analyse and respond to enquiries relating to patient flow.

To understand the common needs and safeguarding issues of vulnerable patient groups, including the elderly and those with long term conditions.

To understand the legal; ethical and regulatory principles of the NHS and know personal boundaries and when to seek help.

To work under supervision to assist in the discharge pathway process ensuring that patients are managed in the most appropriate environment.

To work and liaise with ward and community staff in the identification of blockages in the patient’s journey, ensuring that all outstanding issues are identified and addressed, within scope of practice.

To rectify all issues which have been identified, escalating to the pathway leads or CRS clinical & operational lead the ones you cannot independently progress.

To assist wards with uncomplicated patient discharges to promote safe and timely discharges.  This will include attending daily multiagency calls, as well as proactively contacting ward teams to ensure discharges are ready and appropriate as planned, with relevant equipment in place. 

 To assist with flow through the CRS pathway, linking with Therapy staff and Domiciliary Care Agencies to ensure care reduction plans and service exits are being enacted in the required timeframes. 

To escalate blockages at any point in the patient journey, proactively linking with internal and external partner to support resolution plans 

To demonstrate knowledge of discharge pathways and out of hospital services, as well as assisting in gaining patient consent to refer patients to 3^rd sector organisations such Age UK and social prescribing.  

Accurately record within the patients EMIS notes as appropriate, as well as updating MDT sheets and therapy handovers with progress, actions and outcomes for each patient’s journey you have had interaction with. 

Ensure effective and regular communication with CRS staff, referring teams and other members of the Trust, relating to progress and updated information. Having the required information to update service managers and the Site Capacity Manager on service capacity, blocks and patient flow on CRS. 

Review patient’s records so that all referrals for specialist opinions, therapy input or diagnostics have been completed or progressed. 

To work closely with CRS domiciliary care agencies and therapy teams to ensure good channels of communication with patients and relatives are maintained at all times with regards to changes in their service delivery and discharge from the service. 

To support the Clinical & Operational Lead and Professional Leads with incidents and investigations arising from delays and flow concerns.

To work with all internal stakeholders to promote effective processes to facilitate hospital discharge, support patient flow through the service and onward referrals through service exits; reducing delays in the patient’s management and maximising service capacity. 

To co-ordinate MDT and patient flow meetings; transcribing formal minutes and enacting any required actions such as liaising with staff, following-up actions or making referrals to internal or external services in line with agreed protocols.

To effectively communicate (in person, via telephone and email) with other teams to effectuate progress in a patient’s journey.

Liaise with Warwickshire County Council teams to coordinate timely and appropriate discharged from the service for those requiring long-term care support. 

Liaise with referring teams to ensure patients that do not meet service criteria have suitable alternate arrangements for discharge.

To notify ward staff of individuals on the service that have been readmitted to hospital, where there is pertinent information that would impact future discharge planning. 

Evaluates own area of work and proposes improvements

Assists in basic training and education at ward level.

Communication

At all times communication with others must be polite, professional and courteous.

Respond to patients, their relatives and other professionals in a polite and professional manner.

Be involved in conversations with patients and carers that may sometimes be emotional, difficult and sensitive.

Direct patients and relatives to the relevant therapy team or care agency when necessary.

To maintain and promote confidentiality at all times

To respond in a friendly and helpful manner to all calls taken from wards and departments.

Communicate with senior staff disseminating complex information, reports and outcomes of meetings.

Communicate with the Clinical & Operational Lead, Professional Leads Clinical and CRS staff to maintain an up to dae CRS contact list with key contacts with internal and external teams who assist with the provision of services for patients.

To summarise and document communication that has taken place on EMIS, as well as the therapy handover and MDT log.