Care Home Pathway Coordinator

Epsom and St Helier University Hospitals; St Helier; On-site; GBP 26,000 - 34,000; Full time

Job summary

St George's, Epsom and St Helier University Hospitals and Health Group is seeking a Care Home Pathway Coordinator based at St Helier Hospital to coordinate discharge planning from hospital to care homes. You will work with ward teams, discharge coordinators, and multi-disciplinary colleagues to ensure timely and safe patient transfers.

The role focuses on improving patient flow, reducing delays and readmissions, and supporting the Red Bag process across the hospital and SWL ICB.

Responsibilities

• Work closely with ward teams and Discharge Co-ordinators within the hospital to identify care home residents requiring discharge planning, ensuring their plans are kept up to date e.g., discharge summaries, Universal Care Plan (UCP) and medication reviews before these patients are taken back home.
• Work collaboratively with the discharge teams and multi-disciplinary teams ensuring all discharge documents are finalised prior to the discharge of patients.
• Ensuring that the hospital teams have relevant information to assess and provide the appropriate treatment plan and that on discharge, care homes have the relevant information to enable continuity of care.
• Escalate most complex and challenging cases to Senior Discharge Co‑ordinators for support or advice.
• To ensure smooth and timely communication between the Trust and partner agencies involved in patient discharge/transfer of care to avoid unnecessary delays.
• Ensure the Red Bag Checklist is reviewed, completed, and actioned by the designated responsible staff member when the patient is admitted and discharged.

Job description

The Care Home Pathway Coordinator will be working within the At Home Team closely with the Transfer of Care Hub (TOCH) and will coordinate all aspects of supported discharges and the single point of discharge from St Helier Hospital to care homes.

The service is to ensure care home residents are not unnecessarily admitted to, or delayed in leaving, hospital to the detriment of their wellbeing and independence. The post holder will seek to improve patient flow, reduce delayed transfers of care (DTOC) and avoid unnecessary readmissions, LOS reduction and reduce 4-hour breach for care home residents.

We are looking for an enthusiastic individual to take up the role of Care Home Pathway Coordinator. The post holder will be based at the St Helier Hospital and will coordinate the activities related to the Red Bag journey for patients coming into the Hospital from care homes and ensure the Red Bags are received in the hospital and returned to the care homes on discharge of patients after hospital episode.

The post holder will work closely with all stakeholders to enable the successful delivery of the Hospital Transfer pathway and the Discharge Process for care home residents. The post holder will facilitate the use of the Transfer Pathway and Discharge activities to support safe and quality care to patients admitted from and to care homes.

Sutton Health and Care is an innovative partnership of providers working across Sutton (GP Federation; Local Authority; Mental Health Trust and Acute Trust) to provide integrated services for the local community. As partners we have the exciting opportunity to put the shared vision for how health and care can be delivered into reality through the implementation of a service model for the provision of community services (adult and children) that truly integrates health and care, physical and mental health and primary and acute care.

We are committed to working with each other and commissioners to co-create a model which when implemented will transform the experience of the people who use services in Sutton and fit the vision of the Sutton Health and Care Plan and the national NHS Long Term Plan.

We firmly believe that the partnership will drive transformational change to the benefit of patients and the local health and care system, getting the system to deliver better person‑centred outcomes and financial sustainability.

St George's, Epsom and St Helier University Hospitals and Health Group cares for a population of four million people in South West London and North East Surrey. Our sites include St George's Hospital, one of 11 major trauma centres in the UK and the largest healthcare provider and major teaching hospital in the area; St Helier Hospital, home to the South West Thames Renal and Transplantation Unit and Queen Mary's Hospital for Children; and Epsom Hospital, home to the South West London Elective Orthopaedic Centre (SWLEOC).

After years of collaboration, our two Trusts became a hospitals group in 2021. While remaining as two separate Trusts, being a hospitals group will help us to collaborate more closely on research, and the development, education, and training of our 17,000-strong workforce.

At gesh we are committed to supporting flexible working arrangements. Applicants are encouraged to discuss any flexibility they may need during the recruitment process.

Role/Advert

1. Work closely with ward teams and Discharge Co‑ordinators within the hospital to identify care home residents requiring discharge planning, ensuring their plans are kept up to date e.g., discharge summaries, Universal Care Plan (UCP) and medication reviews before these patients are taken back home.

2. Work collaboratively with the discharge teams and multi-disciplinary teams ensuring all discharge documents are finalised prior to the discharge of patients.

3. Ensuring that the hospital teams have relevant information to assess and provide the appropriate treatment plan and that on discharge, care homes have the relevant information to enable continuity of care.

4. Escalate most complex and challenging cases to Senior Discharge Co‑ordinators for support or advice.

5. To ensure smooth and timely communication between the Trust and partner agencies involved in patient discharge/transfer of care to avoid unnecessary delays.

8. Ensure the Red Bag Checklist is reviewed, completed, and actioned by the designated responsible staff member when the patient is admitted and discharged.

Ensure the Red Bag remains with the resident while in the hospital and return with a Red Bag containing all the relevant documentation, medication (if required) and personal items.

Track usage of Red Bags and eRedBags by care homes.

Support the process of the Red Bag Scheme in the hospital and SWL ICB including the eRedBag process.