Complex Care Coordinator - Complex Care Support Team

Job overview

This is a 12 month fixed term contract for a practitioner (RGN or AHP) to join the Complex Care Support Team  who are proactive in supporting Children with Medical Complexities across the Trust. It will be a varied role; looking to address the non-medical barriers to discharge that this complex cohort of patients face and will need an enthusiastic, innovative and problem solving applicant who will be able to support and represent the team both internally and externally across the region and nationally.

The team aim to support the complex patient’s journey through Alder Hey and are child, young people and family focused, ensuring that this complex cohort of patients get the optimum support to guide them through their patient stay in Alder Hey and back to their homes and beyond into adult services with care and coordination.

Main duties of the job

• To be a team member within Alder Hey’s Complex Care Support Team providing a substantial contribution to the clinical work of the team: including accepting, prioritising and assessing referrals of children and their families. Providing assessment, Complex Discharge planning arrangements, review and evaluation for children and young people with medical complexity throughout the Trust.
• This role will require the post holder to provide clinical care co-ordination of complex discharge pathways, whilst working collaboratively within a wider multi-organisational team. You will work to developing processes as part of a co-produced service. The post holder will require a working knowledge of commissioning processes.
• You will work in partnership with other health professionals, parents, carers, education and other service providers to ensure a child centred approach to discharge planning.
• In addition, they may provide consultation to professionals from other services and participate in service development.
• To provide cover to other areas of service as necessary to support other members of the team.
• To provide clinical management and oversight of complex care arrangements for patients preparing for adulthood on both an inpatient and outpatient basis.

Detailed job description and main responsibilities

Clinical

• To function as an autonomous senior member of the MDT using experience and knowledge of specialist pathways, out of hospital provision as well as needing to influence discharge decisions
• Complete comprehensive, holistic assessments for patients with complex health needs using a range of assessment techniques and knowledge of the systems within health and social care.
• Interpret assessment outcomes into meaningful formulations of needs and problems that are understandable to the patient, their carers and the wider multi-disciplinary team enabling joint decisions about future management and potential delivery options.
• Being able to recognise and respond effectively to safeguarding issues, adhering to Alder Hey policy and procedure.

• To communicate to the client and family, knowledge of therapeutic      processes, confidentiality and available options involved in their assessment and care plan, to enable them to engage appropriately from a position of informed consent. This will sometimes include communication about highly sensitive material and outcomes.
• Utilising analytical skills, specialist knowledge and experience provide a comprehensive assessment and formulation of the presenting problem taking into account the child’s educational attainment, chronological/ developmental stage, inner world/ emotional wellbeing, the mental health of the child’s parents, the family dynamics and environment, and the broader social context including school.
• Undertake with supervision/consultation, case management of cases of some severity, risk and complexity, co-ordinating multi-disciplinary inputs and working in partnership with other agencies where appropriate.
• To adopt a client centred and sensitive approach to care, collaborating with children, parents and / or carers and education staff in all aspects of the discharge process.

• Participate and where appropriate lead on defined home visits/home care plans with the MDT as part of pre admission, discharge planning and post discharge support.

• To participate in team meetings and multi-disciplinary meetings as required occasionally being required to assertively represent the outcomes of assessments and where appropriate challenge the views of other professionals on the basis of the evidence and reasoned views arising from assessments undertaken by the post holder.