Integrated Discharge Case Manager | North Bristol NHS Trust

North Bristol NHS; Bristol; On-site; GBP 30,000 - 40,000; Full time

Job summary

A regional healthcare provider in Bristol is seeking a skilled professional to join the Integrated Discharge Service. The role involves supporting timely patient discharges, leading team efforts, and communicating effectively with multiple stakeholders to enhance patient care. Applicants should be a Registered Nurse, Therapist, Paramedic, or Social Worker, demonstrating strong communication and problem-solving abilities. The position offers opportunities for impactful care delivery within a supportive team environment.

Qualifications

• Experience supervising and supporting team members.
• Ability to think laterally and problem-solve complex situations.
• Experience in a pressurised environment.

Responsibilities

• Drive and deliver consistently high-quality Board Rounds.
• Support early discharge conversations and engage families.
• Facilitate and deliver safe, timely discharges for patients with complex needs.

Skills

Communication skills

Problem-solving

Team supervision

Knowledge of discharge processes

Education

Registered Nurse, Therapist, Paramedic or Social Worker qualification

Job description

Overview

This is an exciting opportunity to join the Integrated Discharge Service (IDS) based at North Bristol NHS Trust and support the development of the Transfer of Care Hub. The post holder will be a Registered Nurse, Therapist, Paramedic or Social Worker focusing on enhancing the patient, carer and family experience around hospital discharge. You will help ensure there are enough beds for patients and maintain bed flow. You will work with a wide range of health and social care professionals, need to be a confident communicator, and bring knowledge of complex discharge processes while developing to the level required for this post. Experience supervising and supporting team members and involvement in or leadership of change within a pressurised environment are desirable.

You will be a lead in championing the Home First ethos – There’s no place like Home; facilitating timely and appropriate discharges; holding early discharge conversations and driving quality board rounds; driving flow to ensure beds are available for those who need them; and bringing discharge expertise to conversations with patients, families and staff, including supporting Managing Expectations procedures.

Applicants will need to demonstrate effective communication skills with the ability to think laterally and problem solve complex situations, focusing on meeting individual needs. You will be a role model for the Integrated Discharge Service and Transfer of Care Hub within the organisation and the wider system.

NBT Cares is our simple statement describing how everyone goes the extra mile to ensure patients get the best possible care. NBT Cares stands for caring, ambitious, respectful and supportive, underpinned by a positive behaviours framework guiding constructive and supportive collaboration.

This advert closes on Tuesday 30 Dec 2025.

Responsibilities

• To drive and deliver consistently high-quality Board Rounds on every ward, every day by providing coaching and mentoring to the ward MDT; assist with allocation of actions and holding individuals to account
• To be responsible for supporting early discharge conversations for every patient to ensure discharge from hospital at the earliest opportunity and to engage families and the patient in the process (where appropriate)
• To promote the effective completion of the Transfer of Care document for people with complex needs to ensure their needs are clearly described and identified
• To adopt and champion a Home First approach to discharge
• To facilitate and deliver discharges for people with complex needs in a safe, timely and appropriate manner
• To provide an expert resource on all aspects of discharge processes and community service provision to the MDT
• To work with colleagues to develop High Impact User plans for patients identified as high risk of repeat admissions with long length of stay
• To work with partners to support a caseload of highly complex individuals whose discharge may not be facilitated through the Community Transfer of Care hub (examples: homeless people with no health or care needs; self-funded patients; CHC/Fast Track; complex mental health needs or learning disabilities; local areas not covered by Community Transfer of Care Hub; coordination of off-site bed bases such as NBT NWB)
• To work collaboratively with Ward leads to implement and embed the Managing Expectations protocol on an individual basis, escalating to organisational leads when there is no resolution within an agreed timeframe
• To coordinate multi-professional care planning processes and meetings for highly complex patients with multiagency involvement, ensuring actions are identified and completed within an agreed timeframe
• To undertake training and development of new staff members and students through Trust and local induction processes around effective assessment of patient needs
• To escalate any concerns to the IDS Operational Leads in an appropriate timescale while maintaining professional autonomy
• To advise on criteria and processes for DOLs procedure, CHC and CHC Fast Track, Mental Capacity Assessment, Mental Health Act, Safeguarding, Application of Consent, and referral processes including Out of Area Services; to support wards in the restart of a Package of Care and advise where a new referral may be required
• To implement BNSSG operational standards accurately and effectively, ensuring codes are recorded to reflect actual delay and reporting trends to relevant heads of service
• To facilitate actions for admission avoidance and proactively manage readmissions as per BNSSG-wide procedures
• To challenge and prevent cancellation of any discharge, ensuring colleagues understand risks of unnecessary hospital stays
• To liaise with providers including care providers, third-sector services, housing, out-of-area Health and Social Care services, Drugs and Alcohol services to support the Transfer of Care Hub
• To provide a 7-day service, liaising with ward leads, particularly in escalation times
• To use specialist knowledge to support the implementation of NBT policies and procedures to facilitate discharges
• To maintain accurate documentation within IDS such as discharge forecasting, stranded patient reviews and outlier progress
• To work within clusters providing support and supervision to IDS team members to maintain a self-supporting and resilient service
• To assist in the investigation and resolution of discharge-related complaints and implement areas of learning to improve service provision

Communication and Information

• To use excellent communication skills to collaborate within the IDS team and with partners within the Transfer of Care Hub to secure timely and safe discharges
• To maintain a professional manner in all communication with partners and patients, especially when sharing difficult or emotive information, such as managing expectations