At UHBW we are creating two new Transfer of Care Hubs which will form the Home First Team to support our patients with discharge planning from admission through to leaving hospital and into the community; one Hub will be on the Bristol Site and one at Weston General Hospital. The Transfer of Care Hubs will bring together our community partners (Sirona), Local Authorities and Voluntary Sector colleagues across BNSSG to create a new team from multidisciplinary backgrounds.
The Transfer of Care Hub will bring together a multidisciplinary team consisting of, Acute Trust Case Managers, and Patient Flow Coordinators, Social Workers, Local Authority Discharge Coordinators, Sirona Case Managers, Community OT’s, the Homeless Team, Voluntary Services and Flow and Discharge Coordinators.
The aim is to work collaboratively and holistically to support patients building on the ‘Home First’ concept.
If you’re unsure, have a go at our 5 question quiz to make sure this is the right role for you!
Staff Benefits
The Trust is delighted to offer you a wide range of flexible benefits as outlined below:
- We understand that life is not all about work, so in return for your hard work and dedication you will benefit from 27 days annual leave (increasing on length of service) plus bank holidays.
- Industry leading pension scheme.
- Access to a multitude of local and national NHS Benefits and Discounts.
- Extra authorised unpaid Annual Leave.
- Cycle Salary Sacrifice Scheme.
- Blue Light Card Discounts
- Car Park Discounts.
Complex Discharge Manager
The purpose of this role is to be an adaptable, driven and proactive leader for the Integrated Discharge Service which includes a team of specialist case managers and patient flow coordinators. The IDS’ purpose is to ensure timely discharges of all patients who require more than a simple return to existing home setups.
There is significant engagement with multiple internal and external stakeholders, mentoring and coaching for the team members and involvement in various projects, with the ultimate goal of providing the best for our patients throughout UHBW
Some of the clinical responsibilities include:
- Provide specialist knowledge and advice to multi-professional team members in relation to discharge planning.
- Take a proactive role within the ward multi-professional meetings across the Trust and System.
- Be aware of, and proactively manage, the needs of patients and carers within discharge planning.
- Take a lead on planning and facilitating complex discharge at UHBW.
- Support and lead complex discharge planning meetings / best-interest meetings for particularly complex discharges at UHBW.
- Ensure that the Hospital Discharge and Community Support guidance is utilised and followed within IDS / HDT.
- Ensure staff adhere to the CHC Fast track procedure where patients have an end of life prognosis
in collaboration with the Clinical Commissioning Group - Provide expertise and knowledge on Patient Discharge policies, procedures and regulations.
Acute Trust Case Manager
You will report to the Band 7 Complex Discharge Manager and below are some of the purpose of the job role.
- Use your expert knowledge to coordinate, facilitate and drive all patient discharges on the wards.
- Be responsible for a defined caseload working with specific wards on a rota to manage complex discharges, supporting /completing initial assessments for Continuing Health Care (CHC) fast-track assessments, and referrals to Community Transfer of Care Hub (CToCH) for pathway beds
- Liaise with the wider MDT, Clinical Commissioning Group (CCG), local authorities (LA) and CToCH to drive discharge at all levels.
- Ensure that National policies and guidelines are adhered to and to ensure that patients and relatives are at the heart of everything we do, involving, supporting and communicating with them throughout the discharge process.
- Line manage the Discharge Flow Coordinators.
Discharge Flow Coordinators
The Discharge and Flow Coordinator aims to guide the patient’s inpatient journey from admission to discharge, supporting patients to leave the hospital setting at the earliest opportunity with the support and care they need to remain safe in their discharge location. The Discharge and Flow Coordinator will have early conversations with patients/ families/ carers around discharge and work closely with the ward MDT to ensure that the discharge process is efficient.
By doing this, the Discharge and Flow Coordinator will ensure that patients only remain in the hospital for as long as they need to and will optimise their length of stay, making sure ‘flow’ is maintained and beds are available for patients that need them.
The Discharge and Flow Coordinator will be expected to undertake a range of practical duties without direct supervision but will be required to report back on those delegated responsibilities to the MDT ward team and the Acute Trust Case Managers (including, booking transport, prompting assessments to be undertaken, access to the patient’s property).
Top tips for a successful application form
Once you have successfully found a position you wish to apply for, you need to make sure your application does you justice and provides you with the best possible chance of getting an interview. This means reading the job description and person specification and taking time over your application demonstrating your skills and experience.
How good a match are you?
All employers will be judging how well your application matches the ‘person specification’ for the position you are applying for. The applicants who closely match the person specification will be the ones that are shortlisted for interview.
You will need to demonstrate that you do have the skills and experience as set out within the person specification and provide clear examples within the supporting information section.
Complete all the parts of the form!
Read the instructions within the advertisement and application form very carefully and make sure that you complete all the sections of the application form. The information you give in the ‘application for employment’ section will be used to decide if you should be shortlisted for interview.
The ‘personal information’ and ‘monitoring information’ sections will not be used for shortlisting, but will be kept for administrative purposes only.
Provide good supporting information.
The ‘supporting information’ section is your opportunity to sell yourself therefore make sure you use it to your advantage. You should:
- Include any information here that has not been covered elsewhere on the form.
- Be clear and concise, give specific examples of how you meet the essential criteria.
- Simple reading formats (bullet points are good, long sentences could be less impactful).
- Demonstrate why you would be suitable and how you meet the person specification.
- Convince the recruiter that you have the required skills, knowledge and experience.
- Be sure to identify any employment gaps
Apply today:
Band 6 & 7 Roles
http://jobs.uhbristol.nhs.uk/job/v3312155
Band 3 Roles
http://jobs.uhbristol.nhs.uk/job/v3312155
Please note the advert is highly likely to close early due to the high volume of expected applications. We urge you to apply early to avoid disappointment.
Our Service Partners- Sirona Care & Health
Sirona care & health is a Community Interest Company committed to providing local communities with a range of high quality specialist health and social care . For us, it’s about the personal approach; we take pride in what we do and deliver the high standard of care that we’d expect for ourselves and our families.
The Community Transfer of Care Hub (CToCH) manage all referrals into the Discharge to Assess Pathways across BNSSG .
Following a hospital stay, the ethos across Bristol, North Somerset and South Gloucestershire (BNSSG) for all people being discharged is ‘Home is Best’, for some service users who have complex needs or need a period of further assessment this is not practicable and they transfer to a complex assessment bed which is generally in a care home.
During their stay, service users will be given support, along with their carers and families around complex discharge planning. This will enable a timely and safe discharge to the person’s usual residence or to a more suitable location if appropriate.
We actively promote a multi-disciplinary model where staff work closely with social workers, GPs as well as other Acute and Community colleagues, to ensure the people we are supporting are kept at the heart of every decision.
The services operate: 7 days per week, between 08:00 & 18:00
Band 6 Case Manager
Case managers work as part of the CToCH to represent community health services as part of the virtual Integrated Discharge teams.
Case managers complete timely virtual reviews of patients referred for further support and assessment on discharge from hospital to identify their multi-disciplinary needs and where these can be best met in the community.
The team work proactively to support the BNSSG health system, to co-ordinate and facilitate hospital
discharges and maximise patient flow through the hospital into community services.
Some of the responsibilities include:
- Responsible for triaging referrals received by the CToCH. This may be include liaising with the patient, family / carers and ward staff to identify the most appropriate discharge pathway.
- Support the Community Transfer of Care Hub to discuss complex cases with Health and Social Care partners.
- To work to the principle that Home is Best and ensure that Pathway 1 has been consideredprior to any other pathway being explored.
- To utilise multidisciplinary assessment skills and supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment.
- To work collaboratively with partner organisations on a daily basis to develop patient–centred rehabilitation and reablement plans.
- To be able to effectively triage and prioritise a large case–load and be able to adjust daily work plan in response to system wide pressures and escalation.
- To pro-actively optimise, in collaboration with the service leads the usage of Community Rehabilitation Beds and be aware of available capacity on a daily basis.
- Provide coordination for the team on a rotational basis to allocate tasks and manage the team capacity for the shift.
- High level of problem–solving required, gathering information from a range of sources, using professional experience and clinical knowledge to inform decision making. This includes being able to complete mental capacity assessments and make best interest decision where appropriate.
- Excellent written and verbal communication skills required –– liaising with internal and external partners as well as members of the public on a daily basis.
- The role has a direct impact on maximising flow into Home First (pathway 1) services, Community rehabilitation beds (Pathway 2) and Complex assessment beds (Pathway 3), expediting hospital discharges and reducing the length of time patients are in hospital.
- Oversight of the caseload in the acute hospitals. Active case management and accountability of these patients to ensure flow is managed effectively.
Band 5 Case Manager- Sirona
- Responsible for triaging referrals received by the CToCH. This may be include liaising with acute hospital staff, social care and patients and their family and carers to identify the most appropriate discharge pathway.
- Support CToCH – to discuss complex cases with Health and Social Care partners.
- To work to the principle that Home is Best and ensure that Pathway 1 has been considered prior to any other pathway being explored.
- To utilise multi-disciplinary assessment skills and supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment.
- To pro-actively optimise, in collaboration with the service leads, the usage of Community Rehabilitation Beds and be aware of available capacity on a daily basis.
- Excellent written and verbal communication skills required – liaising with internal and external partners as well as members of the public on a daily basis.
- The role has a direct impact in maximising flow into community rehabilitation beds and Home First (pathway 1) services, expediting hospital discharges and reducing the length of time patient are in hospital.
- Oversight of the caseload in the acute hospital. Active case management and accountability of these patients to ensure flow is managed effectively.
Our Service Partners- North Somerset Council
North Somerset Council are pleased to be part of the Transfer of Care Hub, to assist in the seven-day co-ordination of safe discharges, through a trusted integrated system wide approach. We have developed a range of innovative prevention services to support people’s recovery through maximising independence and enabling the optimisation of their outcomes, through a personal and positive experience of discharge.
We are looking for social workers and occupational therapists to be part of our established Hospital Discharge and TEC and Reablement Intervention teams. Working in the Hospitals along with our Community Navigators and Home from Hospital services, who link people into the voluntary sector to maximise the opportunity to discharge people at the point people are ready to leave, preventing long hospital waits and deterioration in physical and mental ability. The roles are hospital based and have a pivotal role in the integrated hub with line management responsibility sitting with North Somerset Council.
Our Service Partners- Bristol City Council
Bristol City Council are please to be partners in the Transfer of care hubs, to assist in the co-ordination of safe discharges through a trusted integrated whole system approach. We have developed a range of innovative preventions services to support people’s recovery by maximising independence and enabling the optimisation of their outcome, through a personal and positive discharge from a hospital setting.
We are looking for occupational therapists and social workers to join us to be part of our established Discharge to Assess service. Working along side our hospital, community nursing and voluntary sectors we will strive to create a person centred service to maximise the opportunity to discharge people at the point they are ready to leave.
The roles are based over two hospital trusts within Bristol.
Occupational Therapist-Hospital Transfer of Care Hub
To assess and review the needs of people needing care and support and their carers, to enable them to achieve an acceptable lifestyle by using rehabilitation techniques, prescribing equipment and adaptations.
- To receive referrals and enable decisions regarding emergency/crisis intervention. To carry a caseload as allocated, with regular clinical and professional consultancy.
- Visit and discuss people’s needs in relation to their home environment, identify priorities & goals and assist them, their families in planning realistically for the future. Work closely with Health & Social Care staff and others in formulating and implementing solutions.
- Undertake reviews of support plans in order to maximise people’s independence, depending on position.
- Provide detailed reports for rehousing to the council and advice on the suitability and adaptability of properties, and prepare detailed reports for high cost equipment or adaptations for additional funding as required and present to relevant panels.
- To inform Service Users and their carers of services available and of their eligibility for relevant benefits and allowances.
- Advise on and enable the creative use of universal and community resources including assistive technology and other equipment.
Social Worker – Hospital Transfer of Care Hub
The social worker will assess the needs of service users and carers, will plan, implement, review and evaluate outcomes for and with individuals. The social worker will ensure the principals of choice and control are used in supporting people to make their own decisions about the way they organise their support and how to manage the risks involved.
- To carry out the statutory duties and responsibilities of Bristol City Council within relevant legislative frameworks. Maintain professional standards including those of Social Work England (SWE), professional capabilities framework (PCF) and
Knowledge and skills statement (KSS) for social workers in adult services. - Manage a workload commensurate with level of competence, qualification & experience, within eligibility criteria, prioritisation of service delivery and available resource.
- To enable self-directed support with service users and carers:
• by undertaking assessments to identify the outcomes and the personal budget for the provision of services,
• by developing and reviewing support plans and provision against outcomes andchanging needs. - To undertake risk assessments and be responsible for actions in situations where a service users safety or liberty is at risk, observing safeguarding adults policies and procedures, the legal principles of the Mental Capacity Act 2005 and the principles of
positive risk taking. - To advise on and enable the creative use of universal and community resources, including assistive technology and other equipment.
- To contribute to the development and supervision of social care workers. To undertake student supervision, depending on the level of experience and position on career progression schemes.
- To concentrate on specific areas of work requiring more developed skills, i.e. promoting best practice in use of the Mental Capacity Act 2005, the Mental Health (amendment) Act 2008 and safeguarding adults policies and procedures.
