Discharge Liaison Nurse

Oxford University Hospitals NHS Foundation Trust; Oxford; On-site; GBP 45,000 - 60,000; Full time

Job summary

Oxford University Hospitals NHS Foundation Trust is seeking a Discharge Planning Lead to drive effective, timely discharge for patients with complex health and social care needs, coordinating across multidisciplinary teams and with community services.

You will chair case conferences, provide education on discharge planning, develop and maintain documentation and audits, and work to reduce delays by implementing ambulatory pathways and ensuring NICE guidance is followed.

Qualifications

• Relevant experience in hospital discharge planning or care coordination.
• Excellent communication with multi-disciplinary teams and patients.
• Knowledge of NICE guidance and Care Act 2014 is desirable.

Responsibilities

• Lead multi-disciplinary discharge planning meetings and case conferences.
• Provide education and support to ward staff on discharge planning and legislation.
• Identify delayed discharges, coordinate with Social Services and care partners.
• Develop and maintain discharge documentation and audits.
• Promote ambulatory pathways and avoid unnecessary admissions.

Skills

Communication skills

Computer literacy

Teamwork and collaboration

Tools

MS Office

Discharge documentation systems

Job description

The post holder aims to facilitate effective, efficient and timely discharge of patients from hospital. Particular emphasis is placed upon complex multi-disciplinary assessments and case conferences including patients with complex health and social care, palliative care or rehabilitation needs.

• To work towards a culture of reducing the number of avoidable admissions and delayed transfers of care, in partnership with primary and secondary care, social services and voluntary organisations.
• To work across professional boundaries, maintaining positive communication links between community and secondary care staff, social services, private and voluntary sector workers and allied health professions to promote collaborative working.
• To ensure that patients have an up to date discharge plan commenced on admission, which is patient cantered and carried out in a timely manner, taking actions to reduce any potential delays.
• Provide advice to all partners with a 'key relationship' and patients/carers/relatives on progressing safe and appropriate discharge and the services available to support this
• To promote an ethos of admission avoidance through use of ambulatory pathways.
• To be involved in developing and maintaining discharge documentation and audits.
• To provide education and support to ward staff in clinical settings on current legislation, discharge planning, and NICE guidance.
• To design, develop and deliver appropriate training packages.
• To be involved in the collection and presentation of inpatients delayed transfer of care information focusing on longest stayers,

• To take the lead role in ensuring that patients are safely discharged from hospital
• Provide expertise, advice and support to ward and care home staff. To ensure that staff gain and maintain appropriate skills and competencies to manage simple and complex discharge needs on a daily basis, and to reduce delay.
• To identify patients whose discharge is delayed and inform Social Services of the most urgent in priority order, to positively influence funding decisions, and by use of specialist nursing knowledge, challenging inappropriate decisions.
• If delays occur, identify causative factors and seek solutions to them in partnership with clinical teams.
• To convene and 'chair' multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
• To work with ward staff to ensure patients have up to date, realistic discharge plans and take action either personally or through delegation to implement, monitor and amend the plans if necessary in partnership with all relevant personnel.
• To ensure ward staff refer appropriate patients, in a timely manner, to ToC team to identify appropriate discharge pathway and issue a Medically Optimised for Discharge Notice where the patient is agreed to be fit for discharge and necessary assessments complete
• Lead and advise in the training and education of all staff in all aspects of Discharge Planning and further relevant developments either in a group setting or on an individual basis
• Co-manage discharge coordinators to ensure they are efficient and effective in their role
• Liaise with Community Hospitals to ensure that available beds are used as effectively as possible and occupancy is maintained at 100% wherever possible
• Maintain accurate and comprehensive documentation and patient records either written or IT based in line with both Trust policy and NMC guidelines.
• Work collaboratively with the Health and Social Care Economy to appropriately place patients
• To initiate and design clinical audits of discharge planning and act on findings making recommendations on change to hospital discharge practice
• To adhere at all times to trust policies for the protection of vulnerable adults
• To act as advocate and support for patients/carers/relatives to improve their experience and discharge from hospital
• To be aware of both national & local issues related to Discharge Planning- NICE Guidance, Continuing NHS Funded Care, Care Act 2014, and Mental Capacity Act 2005.
• Represent the Trust in health and social care discussions relating to patient transfer / discharge processes, forging links with external agencies to improve practice.
• To maintain and update the Trust's Discharges Intranet Site
• Implement and uphold the Oxfordshire Protocol of Choice
• Maintain a 'Ready List' of inpatients detailing their discharge plans
• To take a lead in ensuring patients who meet the eligibility criteria for continuing health care are identified and assessed appropriately. Good computer skills, Good communication, You must have appropriate UK professional registration. Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research.

The Trust comprises of four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury. Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call this Delivering Compassionate Excellence and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence., Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. The Trust comprises four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury. For more information on OUH please view OUH At a Glance by OUHospitals - Issuu Our values, standards and behaviours define the quality clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call this Delivering Compassionate Excellence and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence. These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via the OUH YouTube channel., Sexual Safety Charter: In 2023 NHS England launched its first sexual safety charter, and our Trust proudly signed it. We pledge zero tolerance for inappropriate sexual behaviour and commit to the ten core principles Oxford University Hospitals promotes a safe, respectful hiring environment. If you want to make a difference with us, come and join our team. Together, we will uphold the highest standards of care and professionalism.