Discharge Support Worker

Shropshire Community Health Nhs Trust; Shrewsbury; On-site; GBP 40,000 - 60,000; Full time

Job summary

A community health organization in Shrewsbury is seeking a key member for its Care Transfer Hub. The role involves assessing and discharging patients with complex needs, ensuring a smooth transition from hospital to home. Successful candidates will coordinate care plans and work with multidisciplinary teams to enhance patient outcomes. This position emphasizes integration and partnership within health and social care services, making it vital for improving patient recovery times. The role calls for strong assessment and communication abilities.

Qualifications

• Experience in healthcare, particularly in discharge planning or community health.
• Ability to assess patients with complex needs effectively.
• Strong communication and coordination skills.

Responsibilities

• Identify and assess patients for discharge with complex needs.
• Coordinate services including community response and reablement.
• Work collaboratively with multidisciplinary teams for effective discharge.

Job description

The post holder will work within the Care Transfer Hub providing a community focused approach to discharge planning and assessment, embracing the principles of a Discharge to Assess Model and providing a person-centred approach to care.

The role and service offer integration and partnership working with team managers, nurses, therapists, health and social care coordinators across both organisations to ensure a seamless service.

The Care Transfer Hub plays a vital role in reducing delays for patients who are medically fit for discharge. Evidence shows that individuals recover more quickly and completely in a home environment, yet historically, many remained in hospital due to fragmented systems and siloed working across health and social care.

CTH is tackling this challenge head-on by integrating services and professionals under one roof. This includes discharge coordinators, healthcare professionals, social workers, social care officers, community matrons, district nurses, and reablement services all working collaboratively to streamline the discharge process.

The post holder will be a key member of the multidisciplinary health and social care Integrated Discharge Team.

Responsibilities

The post holder will be instrumental in the identification, assessment and discharge of patients with complex needs from the hospital setting, agreeing the discharge pathway and services including home and bed based reablement services, urgent community response (UCR) services including admission avoidance/Virtual Wards and community teams. The post holder will co-ordinate and navigate the patient across pathways to ensure timely discharge for patients deemed fit for discharge.

About the Trust

Shropshire Community Health NHS Trust provides community-based health services for adults and children in Shropshire, Telford and Wrekin, and some services in surrounding areas too. These range from district nursing, health visiting and running four community hospitals through to providing very specialist community care through talented and dedicated staff.

Patients, carers and the public play a vital role in helping us to develop and improve our services and we are constantly looking for ways to work with local communities, patients and the public to innovate and improve. Have a look at the Have Your Say section of our website to find out how you can feed back your experiences and help us to continually improve.

Shropshire Community Health NHS Trust is an exciting place to work. It offers a wide range of employment opportunities for many people.

Shropshire Community Health NHS Trust positively encourages applications from all areas of the community, regardless of age, gender, ethnicity, disability, sexual orientation or religious beliefs. We are committed to ensuring people who work for the community trust have a good working life – and a good work life/home life balance.