Job summaryThe Discharge Key Worker is responsible for coordinating and facilitating safe, timely, and effective discharge planning for patients undergoing surgical care on their assigned ward. Acting as the central point of contact throughout the patient's admission, the post holder works collaboratively with the multidisciplinary team, patients, families, carers, and external health and social care providers to ensure seamless transitions from hospital to home or onward care.
The role focuses on identifying discharge needs at the earliest opportunity, proactively managing barriers to discharge, and ensuring that appropriate assessments, referrals, equipment, medications, transport, and community services are arranged in a timely manner.
This is a cross-site role, and the post holder will be expected to work across both acute hospital sites to support the delivery of the Surgical Discharge Service.
Main duties of the jobTo work closely with the clinical inpatient care groups and discharge team highlighting patients with complex needs, specifically those patients who are deemed to have No Criteria to reside in an acute hospital bed where supported intervention is required to progress the discharge plan.
- Act as a key point of contact for patients, relatives, carers, and members of the multidisciplinary team regarding discharge arrangements.
- Participate in daily multidisciplinary board rounds, discharge planning meetings, and patient flow discussions.
Ensure all inpatients have a discharge plan commenced on admission, an expected date of discharge in line with the no criteria to reside (no C2R) guidance, the SAFER Care Bundle and manage discharge dependent actions to reduce any potential delays.
- Identify potential barriers to discharge at the earliest opportunity and develop plans to address delays proactively.
To work in partnership with the ward MDT, the system SPA (Single Point of Access team) Cluster teams, social services, community care providers, integrated care boards and the discharge team and voluntary agencies regarding simple and complex needs identified during the admission process to provide effective discharge planning to patients and their representatives that facilitates timely discharge.
About usUHD are investing, developing and transforming Trust services in line with the New Hospital Programme. As part of this, some services may move site this year or next, either temporarily or permanently. Recruiting Managers will be happy to answer any service-specific questions at interview.
If a role or service relocates as part of a planned move, excess mileage will not be reimbursed. Travel from home to the new work base will be classed as a normal commute. Any other changes will be managed under Trust or national terms and conditions.
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Job responsibilitiesThe Discharge Key Worker is responsible for coordinating and facilitating safe, timely, and effective discharge planning for patients undergoing surgical care on their assigned ward.
To work closely with the clinical inpatient care groups and discharge team highlighting patients with complex needs, specifically those patients who are deemed to have No Criteria to reside in an acute hospital bed where supported intervention is required to progress the discharge plan.
- Act as a key point of contact for patients, relatives, carers, and members of the multidisciplinary team regarding discharge arrangements.
- Participate in daily multidisciplinary board rounds, discharge planning meetings, and patient flow discussions.
Ensure all inpatients have a discharge plan commenced on admission, an expected date of discharge in line with the no criteria to reside (no C2R) guidance, the SAFER Care Bundle and manage discharge dependent actions to reduce any potential delays.
- Identify potential barriers to discharge at the earliest opportunity and develop plans to address delays proactively.
To work in partnership with the ward MDT, the system SPA (Single Point of Access team) Cluster teams, social services, community care providers, integrated care boards and the discharge team and voluntary agencies regarding simple and complex needs identified during the admission process to provide effective discharge planning to patients and their representatives that facilitates timely discharge.
Communicates effectively with a range of people about day to day tasks as required within limits of job role and training.
Ensure all documentation applicable for the role is recorded accurately, legibly, signed and Job description dated in accordance with trust policies and procedures.
Work with MDT to ensure holistic care for patients and their representatives
Listens to and respects the needs of patients and/or colleagues.
Applies appropriate communication methods using a range of verbal and nonverbal skills helping patients/relatives overcome barriers to understanding when English is not their first language. Treats everyone in a friendly and courteous manner
To provide discharge planning expertise to patients and their representatives during the admission process
Identify patients with cognitive impairment and highlight need for mental capacity assessments to support the discharge planning process.
Facilitate and coordinate discharge plans at appropriate meetings including daily handovers, MDT meetings, care reviews and / or case conferences to agree and finalise discharge plans with patients and next of kin.
Liaise with care agencies and care homes to establish dates for assessments and agree transfer dates Escalate issues and barriers affecting a patients discharge to the clinical leads/MDT in line with the trusts escalation matrix in the Discharge Planning Standard Operating Procedure
Person SpecificationEssential- NVQ level 3
- Experience of working in a hospital setting
Desirable- Experience of working with patients requiring CHC and social services
- Use of IT clinical systems such as ecamis
Essential- Good communication skills
DesirableEssential- Knowledge of comples discharge planning process
- Understanding of MDT assessment for frail surgical patients
Desirable- Knowledge of integrated care systems
- Experience of patient flow
Disclosure and Barring Service CheckThis 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.
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. 
