Job overview

Discharging an individual on to the right care pathway when they no longer need to remain in a hospital or community bed requires a whole system approach. Every local health and care system has a Care Transfer Hub where (physically and virtually) relevant community services across sectors (e.g. health, social care, housing, voluntary sector) are linked together.

The hub coordinates care for people who require care and support after discharge from hospital, and any support for unpaid carers providing care. This covers any patient discharged from hospital or community beds regardless of the area they are resident in.

The hub is staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support if needed. Decisions about what long-term support package is needed should not be taken in hospital wards.

The hub provides a single point of contact for professionals and families/carers in relation to discharge planning and delivery.
The hub operates 7 days a week, 364 days per year ensuring that discharges are timely.

The hub supports safe discharges through close working with the acute and community wards, quality assurance of information and practical support, including proactive early identification of those who may become ready for discharge, supporting planning as early as possible following admission.

Main duties of the job

To facilitate effective discharge practice by providing support and expert nursing advice to STH, SCC, patients and their carers. Supporting Nurses, Therapist, Admins and Discharge Navigators directly to plan for safe timely discharge.

To work closely with the other professional leads in the Hub to identify and mitigate risks to service delivery. To work effectively together in the interests of the patient.

Provide operational support and leadership to all Care Transfer Hub staff.

Provide clinical support and leadership to the Registered Nursing Care Transfer Hub Workforce.

To deputise for the Care Transfer Hub Manager (Physical).

To support the Care Transfer Hub, implement any operational changes to the service.

To support the Care Transfer Hub Manager (Physical) in prioritising workload and allocating team members and resources.

To promote the use of digital systems to improve sharing of information between teams (internal and external).

Attend board rounds to understand patient needs and champion the “Home First” approach.

To lead multidisciplinary team (MDT) meetings to unblock problems and keep the team on track with focus on where possible getting the patient home, reducing delays in the transfer of care to improve the patient outcomes.

Promote the "Discharge to Assess" model in all patient interactions and MDT discussions and always think why not home, why not today.

Working for our organisation

You will be working for an organisation which values and respects all of its staff and the community it serves. The Trust is a leader in the NHS and research sectors and provides excellent benefits for its employees. This includes commitments to professional development but also many policies to support employees in balancing their personal and professional lives.

The objective for the team is to lead discharge planning for patients leaving hospital on all pathways and ensuring that as many patients as possible get the support they need to go home. The Care Transfer Hub should be involved with complex patient discharge from early in admission to plan for and mitigate problems.