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Onward Care Discharge Facilitator

Linkit Recruitment





Posted: 17/03/2023

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LRL are recruiting for two Onward Care Discharge Facilitators.

Purpose of the role:

To work as part of a small and experienced team to help demonstrate the viability of this new service offer through a 4 month proof of concept (PoC)
To support timely discharge of hospital inpatients that are clinically fit for discharge, meet agreed PoC criteria, and to put in place non-clinical support that will help reduce the chances of the discharged inpatients (clients) having future unplanned readmissions
Liaise with the hospital Discharge Facilitator/ Team and or ward staff to identify clients that meet inclusion criteria
To meet with prospective clients and their carers to explain the service, obtain consent, develop and mobilise their home care plan
To provide feedback to the Service Manager on this role, client engagement, and any additional information that may help inform the future development of the serviceGeneral Responsibilities:

Responsible for delivery of the non-clinical care pathway over 12 weeks and until the client is discharged
Ensure excellent client and stakeholder interfaces to promote the quality and effectiveness of the service
In person and telephone base discharge support
Rapid response to hospital discharge team, executing assessment/care planning within 24-48 hours of contactFor patients pre discharge from hospital:

Liaison with nominated hospital services discharge co-ordinator to discuss clients for inclusion
Demonstrate a clear understanding of inclusion and exclusion criteria and work constructively with hospital discharge team members to select appropriate patients for the service
Consent the client to be part of the service
Review the client's hospital discharge plan in conjunction with the hospital discharge coordinator to identify any gaps that need to be filled in order to help the client to stay well and safe at home.
Liaison with hospital OT, therapy and discharge support services to ensure required home environmental assessments have been completed
Write a post discharge electronic care plan and agree it with hospital discharge coordinator
Conduct a home review for the client in conjunction with the agreed discharge plan and OT/ therapy assessment to see what pre-discharge activities have been requested to support the clients discharge from hospital. e.g., stair rail added/ wheelchair ramp/ house deep clean
Liaise with local service providers (NHS, local authority, community, falls service, voluntary sector) to mobilise local services to support the client
Identify any gaps/ delays in local service provision of required activities/ services and outsource. With the support of local social prescriber if available
Agree with the client/ carer which non-clinical home monitoring technology, for instance humidity detectors/ mobility detectors, will be installed and put those devices in place (may be done post discharge) Post discharge:

Call or visit the client on day of discharge to assess how they are coping now back at home
Provide non-clinical advice to the client or their carer where possible in line with their post discharge care plans, for example to help them remember to take their medicines, provide advice on nutrition and adequate hydration, and signpost to local existing services where necessary
Review the results from the non-clinical monitoring at a fixed point each day to identify early if the client's activities of daily living (sleeping, step count, kitchen activity) are changing. If so, follow agreed escalation protocols
Talk to the client/ their carer to understand what is most important to them and what they would like to be able to do in 6 months/ 1 years' time (Patient Activation Score).
Provide non-clinical coaching to support this and liaise with local services to support this
Provide access to Sodexo concierge service in order to source providers for support services the client may require e.g., dog walking, home repairs, weekly shopping), if not covered above
Review progress towards these aims at 6 and 12 weeks
Respond to any calls from the client or their carer and give non-clinical advice
Call the client at the end of the 12 weeks to make sure they are clear who is providing them with what care going forward (from their local care providers)
Provide a summarised close off report to hospital provider discharge co-ordinator, and any other parties agreed with the NHS Contracting Organisation - transmitted securely and compliant with relevant IG.Audit and Compliance:

Accurate note taking and ability to explain tasks done and time taken
To support Quality Assurance (QA) with departmental audits
To support QA with detailed care pathway audit
To support QA with random spot checks and audits as required to support business needsPoints to note:

Clinical responsibility transfers from the hospital to the community upon discharge as usual. Sodexo does not take clinical responsibility for the clients
The services delivered are assessed as being outside the remit of CQC regulated activities, therefore CQC registration is not required
The role is to deliver non-clinical services with the aim of supporting the health and wellbeing of the client. No activities classed as 'Personal Care' by the CQC are to be undertaken, for instance any physical support to the patient (a full list will be included as part of training)Location:

The role holder will need to live in the Buckinghamshire area. The role is home based, with at least 50% of the time, and up to 90% for the first month, spent in the local hospital (Stoke Mandeville) or in client's homes.Hours:

The service will run from 0700hrs - 2000hrs Monday to Friday with weekend on call support across similar hours.
The service will run across three shifts and the role holder will need to cover a combination of early, middle or late shifts as well as weekend on callsRequirements:

Proven track record working in the care sector
Experience in leading and managing teams
Ability to prioritise effectively
Planning and organisational skills
Strong communication skills
Customer Relations skills
Driver with own vehicle and appropriate insurance
Must be IT literate
DBS cleared
Healthcare professional with experience (current registration not required)Salary:

c£31,000 per annum.

Please contact our office on (phone number removed) or email

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