Main Responsibilities

Discharge Planning and Coordination

Lead the planning, coordination and implementation of discharge arrangements for children and young people from admission through to discharge.

Ensure proactive discharge planning is commenced at the earliest opportunity and is embedded within daily clinical practice.

Coordinate safe and timely simple discharges by ensuring all discharge requirements are completed, including documentation, medication provision, follow-up arrangements and communication with families and primary care providers.

Act as the lead coordinator for complex discharges involving multiple agencies, specialist services and community providers.

Facilitate multidisciplinary discharge planning meetings and case conferences to ensure timely progression of discharge plans.

Identify and escalate barriers to discharge and work collaboratively with operational and clinical teams to minimise delays and optimise patient flow.

Monitor patients with extended lengths of stay and implement actions to facilitate safe discharge in a timely manner.

Support achievement of Trust targets relating to length of stay, discharge efficiency and patient flow.

Criteria-Led Discharge

Lead the development, implementation and evaluation of criteria-led discharge pathways across paediatric services.

Work collaboratively with medical teams to establish agreed discharge criteria for appropriate patient groups.

Support nursing staff to undertake criteria-led discharge processes safely and effectively.

Provide specialist advice and clinical oversight regarding discharge criteria and patient suitability.

Monitor compliance with criteria-led discharge pathways and identify opportunities for quality improvement and service development.

Undertake audits and contribute to reporting on pathway effectiveness and patient outcomes.

Children with Medical Complexities

Act as the specialist discharge lead for children with medical complexity, long-term conditions and ongoing healthcare requirements.

Coordinate complex discharge pathways involving continuing care, specialist equipment, home care packages, community nursing support, respite services and safeguarding considerations.

Work in partnership with tertiary centres, specialist teams and external agencies to ensure coordinated care plans are developed and implemented.

Support the development of personalised discharge plans that promote safe care closer to home wherever possible.

Ensure all required services, equipment and support packages are in place prior to discharge.

Provide expert advice to clinical teams regarding discharge planning for children with complex healthcare needs.

Parent, Carer and Family Training

Assess the educational and support needs of parents and carers in preparation for discharge.

Develop and deliver structured training programmes to ensure families are competent and confident in managing their child's care at home.

Provide training and assessment relating to:

• Medication administration
• Enteral feeding
• Tracheostomy care
• Oxygen therapy
• Suctioning procedures
• Seizure management
• Medical equipment use
• Central venous access device care
• Other specialist care requirements

Maintain records of competency assessments and ensure appropriate documentation is completed.

Provide ongoing support and reassurance to families, recognising the emotional and psychological impact of caring for a child with complex healthcare needs.

Promote family-centred care and involve children, young people and families in decision-making throughout the discharge process.

Staff Training and Education

Act as a specialist resource for discharge planning across Children's Services.

Develop and deliver education and training programmes relating to discharge planning, criteria-led discharge, patient flow and management of complex discharges.

Support the development of nursing competencies and discharge-related learning resources.

Provide mentorship and coaching to nursing and multidisciplinary colleagues.

Promote best practice and evidence-based approaches to discharge management.

Contribute to induction, professional development programmes and service-wide educational initiatives.

Support staff to understand community pathways, continuing care processes and available support services.

Transition to Adult Services

Lead and support the planning of effective transition pathways for young people moving from paediatric to adult healthcare services.

Work collaboratively with adult service providers to ensure a coordinated and seamless transfer of care.

Facilitate transition meetings involving young people, families and relevant multidisciplinary professionals.

Support young people to develop independence and self-management skills where appropriate.

Monitor transition outcomes and contribute to service improvements aimed at enhancing patient experience.

Partnership Working

Develop and maintain effective working relationships with:

• Community Children's Nursing Teams
• Health Visitors
• General Practitioners
• Allied Health Professionals
• Education Providers
• Social Care Teams
• Continuing Healthcare Teams
• Local Authorities
• Voluntary and Charitable Organisations
• Regional Specialist Centres

Work collaboratively to coordinate timely assessment, provision of services and implementation of support packages required for discharge.

Act as a key point of contact for external agencies regarding discharge planning and community support provision.

Attend multidisciplinary and multi-agency meetings as required.

Service Development and Commissioning

Support the ongoing development of paediatric discharge services and community pathways.

Work with operational, commissioning and clinical teams to identify service gaps and opportunities for improvement.

Provide specialist knowledge and expertise to support business cases, service redesign and pathway development.

Contribute to commissioning discussions regarding services for children with medical complexity and community-based care delivery.

Collect, analyse and present activity and outcome data to demonstrate service impact and support future service planning.

Participate in audits, quality improvement projects, research and service evaluations.

Support initiatives that reduce avoidable admissions and facilitate earlier discharge where clinically appropriate.

Operational and Bleep Holder Responsibilities

Undertake discharge coordination and patient flow bleep holder duties as required.

Provide expert advice and support to clinical areas regarding discharge processes and capacity management.

Act as an escalation point for complex discharge issues and delays.

Support operational management of paediatric capacity and patient flow during periods of increased demand.

Maintain effective communication with bed management, site teams and operational managers.

Escalate risks and concerns in accordance with Trust policies and procedures.

Clinical Responsibilities

Maintain professional registration and clinical competence in accordance with NMC standards.

Undertake direct clinical care and clinical shifts where required to support service delivery and operational pressures.

Maintain advanced knowledge of paediatric nursing practice and discharge management.

Provide specialist assessment, advice and support regarding discharge readiness and ongoing care requirements.

Ensure all care is delivered in accordance with national guidance, Trust policies and safeguarding procedures.

Promote safe, high-quality and evidence-based care at all times.

Leadership and Professional Responsibilities

Provide visible clinical leadership across Children's Services.

Act as a role model for high standards of patient-centred care and professional practice.

Lead service improvement initiatives relating to discharge planning and patient flow.

Support achievement of organisational objectives relating to quality, safety, efficiency and patient experience.

Develop and maintain positive relationships with colleagues across acute, community and social care settings.

Ensure compliance with clinical governance, safeguarding, risk management and information governance requirements.

Maintain own professional development and contribute to the development of others.

Key Outcomes

• Timely and safe discharge of children and young people.
• Reduction in delayed discharges and avoidable bed days.
• Improved patient flow and capacity across Children's Services.
• Increased utilisation of criteria-led discharge pathways.
• Improved family experience and satisfaction.
• Safe management of children with medical complexity in community settings.
• Effective transition of young people into adult healthcare services.
• Enhanced partnership working across health, social care and commissioned services.
• Improved staff knowledge, confidence and competency in discharge planning.