Worthing NMHT Acute and Community Transition Practitioner

Sussex Partnership Nhs Foundation Trust; Worthing; On-site; GBP 32,000 - 42,000; Full time

Job summary

Sussex Partnership NHS Foundation Trust in Worthing seeks a Band 6 Nurse, Social Worker or Occupational Therapist to join the Worthing Neighbourhood Mental Health Team as an Acute and Community Transition Practitioner. The role bridges acute and community services, ensuring smooth transitions for patients moving between settings.

Key duties include leading admissions to acute hospitals, coordinating with carers and external services, and overseeing complex discharge planning for up to 4–6 weeks

Qualifications

• Registered professionals in nursing, social work or occupational therapy.
• Experience coordinating acute-to-community transitions and discharge planning.
• Ability to liaise with carers, families and external services.

Responsibilities

• Attend acute and community meetings (Crisis Team MDT, ward huddles, discharge planning).
• Lead Practitioner for new admissions to acute hospitals and ECR beds for 4–6 weeks post-discharge.
• Coordinate with carers, families and external services (CGL, Social Care, Talking Therapies).
• Support inpatient services to achieve timely discharges and robust discharge planning.
• Maintain oversight of patients with complex needs and ensure safe pathways.

Skills

Discharge planning

Interdisciplinary teamwork

Communication

Leadership

Education

NMC registered nurse

Social worker qualification

OT qualification

Job description

We are seeking a Band 6 Nurse, Social Worker, or Occupational Therapist to join our Worthing Neighbourhood Mental Health Team as an Acute and Community Transition Practitioner. This is a pivotal role bridging acute and community mental health services, ensuring clients experience a smooth, well-coordinated transition as they move between settings.,

• Attend all relevant acute and community meetings, including Crisis Team MDT meetings, ward risk huddles/bed meetings, ward rounds, discharge planning meetings, and ATS zoning meetings.
• Act as Lead Practitioner for all new admissions to SPFT acute hospitals and ECR beds who are not already known to the service -- providing active involvement from admission through discharge, and for 4-6 weeks post-discharge. At the end of this period, either discharge to primary care, signpost to other agencies, refer to Pathfinder, or request allocation to long-term support.
• Liaise effectively with carers and families, and maintain strong links with Urgent Care, Havens, and the Staying Well Service.
• Coordinate with team Lead Practitioners supporting clients currently in hospital, facilitating liaison with ward staff as required, including discharge coordinators and clinical bed managers.
• Build and maintain effective relationships with external organisations, including CGL, Adult Social Care, and West Sussex Talking Therapies., As an Acute and Community Transition Practitioner you will be working closely with colleagues in our hospital discharge teams, to ensure that we achieve timely and safe discharges for patients. You will have oversight of all patients identified with complex needs, ensuring that the discharge planning and pathways are being robustly and proactively managed for these individuals.

You will play a key role in supporting our inpatient services in achieving timely discharges, supporting our aspiration to offer care and treatment for all patients within the most appropriate environments. In line with our Trust value of 'People First', evidence shows that people who are treated nearer home and in the least restrictive manner, have better outcomes. You will work collaboratively with our multidisciplinary team and our Adult and Older Adult Services, to help us provide this opportunity for the people of Sussex.

Community mental health services are undergoing a real transformation, and you could be part of these exciting developments. Our community mental health teams are becoming part of a more integrated network of services, with our mental health clinicians playing a central role in driving these changes in close partnership with colleagues in primary care and the third sector. We recognise that working in mental health can be stressful, so we prioritise staff welfare, providing regular supervision, reflective practice, mentoring, and any other support that our clinicians need to ensure their wellbeing.

What you will receive from us:

• Regular Line Management Clinical and Professional supervision
• Access to a wide range of Training and CPD opportunities including;
• The opportunity to participate in a range QI work and service innovations
• Varied leadership development opportunities.