Transfer of Care Hub Clinical Practioner

Detailed job description and main responsibilities

RESPONSIBILITIES

The post holder will:

·       The role will coordinate the multidisciplinary triaging of referrals for discharge.

·       Use clinical knowledge and skills to triage referrals and accurately convey the patient’s care needs, to ensure that an appropriate care provider can be sourced.

·       Provide and receive complex, sensitive, or confidential information with empathy and reassurance, even in difficult, emotional, or hostile situations involving patients or clients, some of whom may have special needs.

·       Provide expert advice and identify appropriate resources and strategy to case managers to ensure that the patient's journey is effectively case managed.

·       Work closely with VCSE (Voluntary, Community and Social Enterprises) and Age UK and ensuring referrals to these services are identified during the triaging and the meeting for on-going support in the community.

·       Proactively monitor progress of the referral and ensure the tracker is up to date with information, identifying delays and ensuring actions are followed up to minimise the delays of patients who do not meet the criteria to reside.

·       Demonstrating skills in analyzing complex patient needs, reviewing referrals accurately, and coordinating effective transition of care to ensure seamless continuity of care.

·       The role involves frequent light physical effort, such as walking and standing while assessing patients, with occasional moderate effort like kneeling or crouching; manual handling may sometimes be needed but is not always required.

·       Ensure timely referrals are made through the pathway to enable timely discharge from the acute and non-acute settings.

·       Where necessary, respond to the escalating needs of patients who have been identified for case management, and liaise with the MDT team to expedite discharges.

·       Produce timely, function-specific advanced reports and analyses.

·       Enhancing the work of the TOCH to allow improvements throughout.

·       Positively contributing to system working and collaboration in the expansion of the Transfer of care hub

 2. Quality

·       Participate in the development of guidelines and policies, quality initiatives, and audits.

·       Support the Service Lead in investigating any concerns or complaints raised.

·       Work in partnership with health and social care teams, sharing in the care programmes required for case-managed patients.

·       Liaise with the multidisciplinary teams during a patient’s admission to ensure robust discharge, care planning, and ongoing follow-up to support the patient back in their own home/discharge destination.

·       Support the implementation, monitoring, and reporting of performance outcome measures, alerting managers of any issues or shortfalls.

·       Complete data collection as required, entering data onto the appropriate database within the required time frames.

·       Alert the Service Lead to any unresolved issues in a timely manner or in the absence of the Service Lead, escalate to the relevant senior managers.

·       Contribute to the development of processes within the Transfer of Care Hub Process.

·       Working with the team to ensure Key performance indicators are adhered to.

 3. Resource Management

·       Ensure effective and efficient use of available resources to meet patients’ needs.

·       Reprioritise the workload of the team to meet changing demands and priorities.

·       Ensure effective relationships/liaison with Primary Care, social services, Community Services, Home Care agencies, and the MDT team to enable a coordinated team approach to care.

·       Use excellent communication skills in liaising with people, carers, and relatives.

·       Foster excellent relationships with health and social care agencies

·       Be a change agent actively facilitating changes in practice, including the challenging of professional and organisational boundaries, which will improve outcomes and meet the needs of patients and carers.

·       Be flexible in your working arrangements.

 4. Risk Management

·       Ensure actions are taken to support any risk assessments undertaken.

5. Record Keeping

·       Ensure accurate, contemporaneous records are kept that ensure safety and continuity of electronic and paper patient records.

·       Identify any barriers to the keeping of contemporaneous and accurate records to enable the resolution of these issues.

·       Provide timely information as requested, including statistical returns as required.

6. Professional Development

·       Participate in activities related to individual or team development.

·       Maintain appropriate and up-to-date knowledge and skills and undertake educational activities in accordance with personal and service needs within a framework of appraisal and Personal Development Plan.

·       Promote personal and professional and clinical expertise through continuous professional development.

·       Where the post holder has particular expertise, to act as a resource to other health care professionals, including providing training and/or supervision where required.

·       Actively reflect on practice and the care provided and use learning to inform and improve future care.

7. Educational Responsibilities

·       Attend appropriate education and training programmes in order to develop skills.

·       Work with the integrated team to develop, implement and evaluate teaching programmes for patients and their carers that provide necessary knowledge and skills for self-care and independence.

·       Provide peer support to other MDT members.

 8. General

·       Be responsive and flexible to meet the needs of the service and individuals

·       Post holder is required to follow trust policies and procedures, which are regularly updated.

·       To be aware of and comply with the correct procedures and responsibilities in terms of identifying and reporting any accidents, incidents, or safeguarding concerns.

·       To possess/develop and maintain the level of information technology skills necessary to complete the role.

·       To work autonomously on a daily basis.

·       Provide oversight, support, guidance, and supervision to administrative staff.

·       including taking responsibility and problem-solving complex situations.

·       Provide a leadership style that is underpinned by the values held within the organisation.

·       To deputise for the service lead when they are absent/unavailable and take responsibility for operational management of the team and ensuring that operational service priorities are met.

·       To contribute to the recruitment and retention process, as required.

·       To undertake and coordinate staff appraisals and performance management.

The duties outlined above are not intended as a restrictive list and may be extended or altered to include other tasks that are commensurate with the grade.