Job summary
The post holder will assist and provide a proactive and efficient case management for all adult mental health patients across all ELHT hospital sites. They will provide education and advice to maintain a high standard of discharge planning processes and work to support the patients onward and ongoing care plans. As a case manager in the Integrated Discharge Service, they will promote the timely access to health, mental health and social care resources to enable the safe and effective discharge of patients from hospital. To 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 clinical advice and guidance to professionals within Integrated Discharge Service.
To support patients identified to have psychological and mild to moderate mental health needs associated with long term physical conditions.
To conduct assessments required for discharge and provide bed base care category recommendations
To triage and signpost patients to the appropriate service within their locality.
Develop robust care plans in conjunction with the patient and wider multi- disciplinary teams, to enable the patient to manage their mental health condition more confidently, which will enhance the ability to manage their long-term conditions.
Provide data that analyses the impact of mental health provision within the Integrated Discharge Service.

About us
Working within the Integrated Discharge Service (IDS) involves supporting timely, safe and effective patient discharge from hospital through multidisciplinary and multi-agency working. The role includes early identification of discharge barriers, coordinating complex discharge plans, liaising with health, social care and mental health services, providing specialist advice to ward teams, managing safeguarding concerns, and supporting patient flow by reducing avoidable delays and length of stay.

Job responsibilities

• Undertake comprehensive mental health assessments for patients with complex mental health needs.
• Utilise recognised assessment tools including 6CIT, PHQ-9, GAD-7, GDS-15, MoCA, DASS-21, MCA and Trusted Assessment documentation.
• Assess emotional, psychological and cognitive needs and their impact on managing long-term conditions.
• Complete risk assessments, including suicide, self-harm and safeguarding risks, escalating concerns appropriately.
• Develop person-centred care plans with realistic and achievable goals.
• Refer and coordinate care with secondary mental health services, GPs and other agencies where required.
• Contribute to discharge planning, best interest meetings and multidisciplinary care planning.

Discharge and Case Coordination

• Support patients through the Enhanced Discharge to Assess pathway.
• Attend ward rounds, discharge planning meetings and multidisciplinary team meetings.
• Monitor patient progress, engagement and outcomes following discharge.
• Coordinate care across acute, community, social care and mental health services.

Communication and Partnership Working

• Provide specialist mental health advice to healthcare professionals, patients, carers and families.
• Develop effective working relationships with GPs, CMHTs, social services, voluntary organisations and acute services.
• Facilitate collaborative, person-centred approaches to care across agencies.
• Maintain accurate, timely and confidential clinical records.

Education, Training and Supervision

• Deliver mental health education and training to healthcare professionals and partner organisations.
• Provide supervision, mentoring and support to staff and students.
• Participate in clinical and managerial supervision and maintain professional registration requirements.
• Promote evidence-based practice and psychosocial interventions.

Service Development, Audit and Governance

• Participate in service improvement, policy development and clinical governance activities.
• Contribute to audits, research projects and quality improvement initiatives.
• Support the development of services for older adults with mental health needs.
• Monitor and evaluate outcomes including patient experience, reduced emergency department attendance and reduced length of stay.

Professional Responsibilities

• Maintain compliance with NMC standards, Trust policies and mandatory training requirements.
• Maintain up-to-date knowledge of mental health legislation, dementia care, safeguarding and best practice.
• Demonstrate accountability, professional leadership and adherence to ELHT values.
• Engage in continuing professional development and appraisal processes.

Key Performance Outcomes

• Improved patient experience and satisfaction.
• Reduced hospital length of stay.
• Reduced emergency department attendance.
• Effective discharge planning and community support arrangements.
• Improved staff knowledge and confidence in managing mental health needs.
• Positive multidisciplinary and stakeholder feedback.

Qualifications
Essential

• Registered Mental Health Nurse (RMN) - current NMC Registration
• Evidence of professional updating and development in the nursing care of patients in an acute or community setting.
• Diploma in Professional Studies (Nursing) - or equivalent.

Desirable

• Teaching & Assessing qualification (or equivalent).
• CBT/PSI qualification
• Non-Medical Prescribing V300 or working towards

Knowledge
Essential

• A minimum of two years post-registration mental health nursing experience
• Involvement in innovative nursing practice and multi-cultural nursing environments
• Team leadership
• Evidence of practicing in an acute mental health inpatient/community care setting.

Special requirements
Essential

• Imagination and determination.
• A questioning attitude.
• A concept of own nursing philosophy
• Enthusiasm.
• Flexibility.
• Ability to work under pressure and meet deadlines.
• A problem-solving approach to professional practice.
• Ability to meet contractual requirements
• Full current driving licence

Desirable

• Ability to assimilate new concepts and approaches to care.
• Ability to respond positively to constructive criticism.

Experience
Essential

• Skills in assessing, planning and evaluating mental health nursing interventions.
• Skills in interacting therapeutically with distressed and/or disturbed individuals
• Skills in individual nursing interventions.
• Skills in teaching, supervision and self-appraisal.
• Skills in multi-disciplinary team-work.
• Skill in interacting effectively with colleagues.
• Ability to cope with stress.
• Excellent presentation skills - both verbally and non-verbally.
• Skill in report writing.
• Skill in chairing meetings
• Skill in motivating and managing change in others.

Desirable

• Skill in basic research process.
• Skill in audit and quality assurance programmes.
• Skills/training in a psychological therapy

Knowledge
Essential

• Extensive knowledge of the various approaches to mental health assessment.
• Knowledge of key areas of liaison psychiatric nursing practice, including the psychological effects of physical illness
• Knowledge of nursing and psychiatric interventions with patients in an acute phase of mental illness/distress.
• Knowledge of risk assessment and management, particularly in relation to suicide
• Knowledge of the clinical and demographic risk factors associated with suicide and self-harm.
• Knowledge of Common Law and issues relating the Mental Health Act (1983).
• Knowledge of the teaching process.
• Knowledge of team-work and staff development.
• Knowledge of the various therapeutic approaches in the care and treatment of patients with delirium, dementia and depression.

Desirable

• Knowledge of basic research methodology

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).