Complex Discharge Coordinator

NHS; Chertsey; On-site; GBP 35,000 - 45,000; Full time

Job summary

A healthcare organization in England is seeking a Complex Discharge Coordinator to provide clinical leadership and facilitate efficient discharge processes. This role involves collaboration with multidisciplinary teams to ensure safe and timely patient transfers. The ideal candidate is a Registered Nurse with experience in leading complex discharges and a strong understanding of discharge planning principles.

Benefits

Excellent pension scheme

Annual leave entitlement

On-site nurseries

On-site staff cafes

Salary sacrifice schemes

Qualifications

• Must be a Registered Nurse with mentorship experience.
• Experience in leading complex discharges required.
• Comprehensive knowledge of discharge planning necessary.

Responsibilities

• Provide clinical leadership in discharge planning.
• Identify delays in the discharge process.
• Coordinate with multidisciplinary teams for effective patient flow.

Skills

Clinical leadership

Multidisciplinary teamwork

Communication skills

Discharge planning

Problem-solving

Education

Registered Nurse

Mentorship/teaching qualification

Degree in a relevant area

Job description

Ashford & St. Peter's Hospitals NHS Foundation Trust

Complex Discharge Coordinator

The closing date is 16 November 2025

• Provide expert clinical and operational leadership to ensure safe, timely, and effective discharge planning for patients with complex needs.
• Work collaboratively across the multidisciplinary team (MDT), community partners, and external agencies to remove barriers to patient flow and reduce delays in transfer of care.
• Act as a key point of contact and specialist adviser for all matters relating to discharge, transfer of care, and complex case coordination.
• Lead on the coordination of complex discharges, ensuring all legal, clinical, and social care considerations are addressed and documented appropriately.
• Support the delivery of the Trust's discharge improvement agenda by embedding best practice, data accuracy, and a "Home First" culture across all clinical areas.
• Ensure every patient's discharge or transfer of care is safe, timely, and person‑centred, in line with Trust policies and national guidance.
• Reduce delays in discharge through proactive case management, early identification of barriers, and collaboration with relevant teams and agencies.
• Provide professional leadership and expertise in discharge planning, supporting staff across the Trust to deliver high standards of care and effective communication.
• Promote a culture of accountability and shared ownership among all clinical teams for discharge planning and patient flow.

Main duties of the job

Proactively identify and resolve delays in diagnostics, treatment, and discharge to ensure smooth patient flow and timely transfer of care.

Lead and coordinate the multidisciplinary team (MDT) and support services during board rounds to meet discharge and transfer KPIs.

Take a lead role in discharge planning for patients with complex needs, liaising with families, social services, community teams, and other partners to prevent avoidable delays.

Chair and coordinate family meetings, ensuring clear decisions, documentation, and collaborative care planning.

Provide specialist advice and leadership to the MDT on discharge planning, funding criteria, legal frameworks, and care pathways.

Act as a key contact for GPs, community partners, and external agencies regarding transfer of care issues and potential delays.

Maintain accurate, timely, and compliant documentation across all Trust systems, supporting audits and performance monitoring.

Promote early discharge and the use of the Discharge Lounge in line with the Home First and Discharge to Assess (D2A) models.

Lead on out‑of‑area and privately funded discharges, ensuring safe and appropriate arrangements.

Support staff education, mentorship, and professional development around discharge processes and best practice.

Provide visible clinical leadership and act as a role model, advocating for patients and supporting staff in complex decision‑making.

About us

Ashford and St. Peters Hospitals NHS Foundation Trust serves a population of more than 410,000 people living in North‑West Surrey, parts of Hounslow and beyond.

Over 3,700 highly trained doctors, nurses, midwives, therapists, healthcare scientists and other support staff make up our workforce, providing a wide range of services across our two hospital sites, Ashford, Surrey and St Peter's, Chertsey, Surrey.

We also run many specialist clinics in the community and local community hospitals and other healthcare facilities.

Our vision is to be one of the best healthcare Trusts in the country. There has never been a better time to join us in the NHS at ASPH. We are committed to providing continuous professional development and flexibility to shape our workforce around our patient care.

We are expanding our theatres at Ashford Hospital and moving towards this becoming our dedicated elective centre. We want to create a state‑of‑the‑art centre for excellence for planned surgical procedures.

We can offer you the full range of NHS benefits/discounts and in addition:

• Excellent pension scheme and annual leave entitlement
• On‑site Nurseries
• On‑site staff cafes
• On‑site parking
• Salary Sacrifice schemes including wage stream, lease cars, Cycle to Work schemes and home electronics

Adverts may close early, so applicants are encouraged to submit an application as soon as possible.

For more information about a career at ASPH please visit: www.asph-careers.org

Job responsibilities

• Identify critical delays in the entire diagnostic, treatment and care processes and generate proactive solutions to speed them up.
• Give direction to members of the MDT and support services (e.g. pharmacy, diagnostics) during board rounds to ensure achievement of transfer of care KPIs.
• Have an in‑depth knowledge of all aspects of care throughout the patient journey and communicate complex information to patients, families or carers sensitively, ensuring language, hearing or cognition barriers are addressed.
• Take a proactive approach to the discharge management of patients with complex needs, communicating with Family/Carers, Social Service, Continuing Healthcare, Community Services, GPs, Care Homes and other providers to identify and resolve health or social care issues early.
• Collaborate with the multidisciplinary team to identify barriers or changes to clinical conditions that may impact on the Estimated Date of Departure (EDD) or Request For Discharge (RFD) and agree management plans to ensure a timely transfer of care.
• Serve as the point of contact for GPs and community partners for issues relating to transfers of care and identify potential delays early.
• Arrange and undertake specialist assessments in line with SOPs and timescales, including initiating supporting assessments such as care diaries, behaviour diaries and ensuring appropriateness.
• Arrange and chair family meetings, ensuring the views of patients, families/carers and the MDT are expressed and understood and clear actions and decisions are documented.
• Provide expertise within the MDT to develop robust discharge plans for complex patients, including consideration of alternative service providers or settings where clinically appropriate.
• Act as a role model at all times, ensuring high quality care is delivered to patients and their families or carers.
• Support the multidisciplinary team by providing advice on complex transfer of care planning, including funding criteria, eligibility, statutory responsibilities, management of challenging family meetings, best‑interest meetings or funding disputes and provision of information about alternative care settings.
• Utilise expert knowledge to liaise with directorates and specialties about the management of patients where a delayed transfer of care is predicted or realised, proposing solutions and changes to practice to resolve the issue.
• Provide clinical and professional support and leadership to the clinical areas as appropriate.
• Leverage holistic knowledge and expertise to assist the MDT.
• Advocate for patients at all times.
• Support the process of D2A and enable patients to be discharged in a same‑day home first approach.
• Case‑manage complex cases on the wards supporting a multi‑professional approach to discharge planning.
• Have knowledge and understanding of Power of Attorney, Court of Protection, Mental Capacity Act, Deprivation of Liberty, use of IMCA and other legal frameworks.
• In the event of a major incident, identify and support the immediate discharge and transfer of patients to facilitate capacity.
• Lead the coordination of family meetings in response to complex discharges to promote effective communication and resolve issues identified early.
• Support wards in highly complex and multi‑professional conversations.
• Lead on Out of Area and Privately funded discharges.

Information and reporting

• Follow the Trust’s Discharge Policy and work with community teams, social services, voluntary, other healthcare colleagues and providers to facilitate timely, appropriate and safe discharge of patients out of hospital to the community.
• Ensure confidentiality of information is maintained and consent is always gained.
• Ensure all assessments are recorded on all electronic systems currently used by the Trust using the correct response times and then stored on the Trust TEAMS drive.
• Maintain complete, accurate and up‑to‑date written and electronic documentation.
• Be actively involved in the Long Length of Stay ward reviews and attend relevant meetings.
• Support any audit or data review related to the discharge process.
• Participate in the weekly delays sign‑off process with social services as required.
• Audit the effectiveness of discharge planning within the acute Trust by maintaining accurate IT records to enable collection and analysis of data.
• Promote early bed release guidelines at ward level to ensure all suitable patients use the discharge lounge.

Education Responsibilities

• Ensure all members of the discharge team understand their role in the education of ward staff and students, acting as a mentor and assessing performance as appropriate.
• In conjunction with the clinical nurse leads and educators, oversee the education of all staff within the Trust regarding discharge planning and identify learning needs, promoting competency via work‑based education.
• Maintain and enhance own knowledge through continuing education and training activities, identifying development needs and establishing personal clinical supervision/mentorship.
• With support from the discharge Team Manager and the CPE team, support the development and implementation of programmes for professional supervision of staff.
• Ensure that all staff are aware of how to report untoward incidents and deal effectively with patients or relatives complaints.

Person Specification

Qualifications

• Registered Nurse
• Mentorship/teaching qualification or equivalent experience
• Degree in a relevant area or evidence of recent study

Experience

• Relevant experience at a senior Staff Nurse level
• Multi‑disciplinary working and ability to provide the lead in interdisciplinary decision making
• Manage conflict
• Experience of working within an MDT environment and leading complex discharges
• Knowledge of the types of funding available for patients entering residential or nursing care

Knowledge

• Comprehensive knowledge of issues related to discharge planning
• Knowledge of the NHS framework and guidance on Discharge Planning
• Experience and/or knowledge of Discharge to Assess

Disclosure and Barring Service Check

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.

Ashford & St. Peter's Hospitals NHS Foundation Trust