Complex Case Manager - CHC Co-Ordinator

Job overview

The post holder will assist and provide a proactive and efficient Complex Case Management Service for all adult patients across all ELHT hospital sites. They will provide education and advice to maintain a high standard of coordination and discharge planning for patients accessing health led community discharge plans. The post will ensure and promote the timely access to health and social care resources to enable the safe and effective discharge of patients from hospital. This post will work in partnership with other interdependent teams and services across the Health and Social Care Economy that are involved in the discharge planning of patients.

Main duties of the job

• To provide pro-active and responsive support to the Head of Complex Case Management/ Integrated Discharge Service Delivery Manager.
• Work across all ELHT sites to meet the needs of an efficient Integrated Discharge service/ Complex Case Management Service.
• Advise assist and navigate ELHT staff through the discharge planning process, specifically in relation to health led planning with a focus on palliative and end of life cases. To plan and meet future care needs to facilitate a safe and timely discharge from hospital.
• To have experience as a palliative care nurse to support community care planning from hospital and where appropriate to assess and support community cases after discharge or in on a needs basis if community support is required.
• To have the in-depth knowledge and skills in palliative care to act as a resource for ward staff at all levels and other multi-disciplinary professionals ensuring there is a consistent and informed approach in relation to effective and timely discharge planning.
• To have the in-depth knowledge and skills in the discharge pathways to act as a resource for ward staff at all levels and other multi-disciplinary professionals ensuring there is a consistent and informed approach in relation to effective and timely discharge planning.

Detailed job description and main responsibilities

• Provide proactive input to all wards to ensure length of hospital stay is determined by clinical need and not by organisational resources.
• To promote and maintain effective communication channels between all Health and Social Care departments/agencies in the acute and community settings.
• Proactively advise and support staff to initiate the early discharge planning of patients with vulnerable/complex needs ensuring appropriate assessments are completed in a timely manner to facilitate discharge.
• Identify, progress chase and monitor delayed discharges and lost bed days within the patient journey and referrals. Escalate delays and concerns to the service leads.
• Operate the Continuing Health Care desk/ processes set up with the Intergrated discharge service, working on own initiative to ensure discharge planning process commences as soon as possible after admission and that immediate discharge is achieved once the patients is medically optimised.
• Contribute to and lead on daily, weekly, and monthly reporting related to the area of work.
• Prioritise own workload to ensure deadlines are met and a quality, responsive service is provided.
• Identify and discuss any potential discharge problems/delays with ward staff and patient/relatives to resolve issues as soon as possible. This will be done on a face-to-face basis.
• Visit wards as appropriate to support the education of complex discharge planning and specific specialised care coordination that is available to support discharge for complex and highly complex patients.
• Alert the Integrated Discharge Service Lead/Head of Complex Case Management of any unresolved issues/conflict/barriers preventing resolution.
• Maintain accurate records and participate in internal or Department of Health audits as required in relation to the discharge planning process.
• Act in accordance with Code of Professional Conduct and ensure current registration is maintained.
• Identify patients approaching the end of life and initiate fast track processes to preferred place of care in accordance with The National Framework for NHS CHC. To include supporting the care planning, care provision and delegated funding authorisation.
• Support and respond to the Trust Escalation Processes, as guided by the Integrated Discharge Service Lead/Head of Complex Case Management and maintain close liaison with the Clinical support unit and other partner teams.
• Contribute to the maintenance of processes which support The Community Care (Delayed Discharge) Act 2003 and ELHT Patient Discharge Policy.
• Ensure compliance with other related Trust Policies and Department of Health Legislation regarding discharge planning processes.
• Support the Integrated Discharge Service Lead/Head of Complex Case Management to implement strategies for ward staff and professionals to determine realistic discharge dates for timely and effective discharge planning patient flow.
• Screen referrals made to the Central Point of Referral in the Continuing Health Care coordination desk in Complex Case Management, signposting to alternative pathways as appropriate to meet identified needs.
• Screening and tracking of referrals, monitoring assessment and transfer timescales.
• Maintain databases Co-ordinate, organise and manage a defined Continuing Healthcare data base.
• Maintain accurate record keeping at all times.