Community Transfer of Care Hub Case Manager

Are you a Nurse or Therapist looking for a community job in a developing service?

Are you passionate about supporting people to return to their own homes following acute illness or injury?

This could be the role for you!

The aim is to work collaboratively and holistically to support patients to get 'Home First' by co-locating a team of professionals from different organisations to streamline complex discharges. To have face to face conversations that facilitate partners working together to maximise opportunities for an early discharge that embraces positive risk taking and keeps the patient at the centre of everything that we do.

The successful candidate will be a key member of the multi-disciplinary team, responsible for providing person-centred, holistic assessment to facilitate discharge from the acute hospitals to the right discharge pathway.

You will need to have experience working in the community setting and an understanding of the levels of clinical acuity that can be supported in peoples own homes. Alongside this you will have an understanding of rehabilitation pathways, discharge planning and mental capacity issues, excellent interpersonal and negotiation skills.

In return, we will provide you with regular training and supervision and enable you to become involved in future service developments.

Main duties of the job

• UHBW have two Transfer of Care Hubs to support our patients with discharge planning from admission through leaving hospital and into the community: one Hub at the Bristol Royal Infirmary and one at Weston General Hospital.
• You will be a key member of the multi-disciplinary team, responsible for providing person-centred, holistic assessment to facilitate discharge from the acute hospitals to the right discharge pathway.
• You will be responsible for triaging referrals received by CToCH. This may include liaising with the patient, family/carers and ward staff to identify the most appropriate discharge pathway.
• Part of your role is to support the CToCH to discuss complex cases with all partners in the Transfer of Care Hub to agree a joint action and discharge plan.
• You will utilise multi-disciplinary assessment skills, supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment
• You will effectively triage and prioritise a large caseload and be able to adjust daily work plan in response to system-wide pressures and escalation. Pro-actively optimising the usage of community capacity on a daily basis.
• There is a high level of problem-solving required, using professional experience and clinical knowledge to inform decision making. This includes being able to complete mental capacity assessments and make best interest decisions where appropriate.

Working for our organisation

We are Sirona care & health, a Community Interest Company committed to providing local communities with a range of high-quality specialist healthcare services across Bristol, North Somerset and South Gloucestershire. For us, it’s about the personal approach; we take pride in what we do and deliver the high standard of care we would expect for ourselves and our families.

At Sirona, we continue to build an inclusive culture that encourages, supports, and celebrates the diverse voices of colleagues, people and communities. We welcome applications from all who feel they have the skills and attributes to make a real difference.

Benefits:

We offer NHS Agenda for Change Salary, Terms and Conditions and the NHS pension scheme plus much more! 

We offer NHS Agenda for Change (AfC) salary including annual leave supplement, Stakeholder pension, a range of health and wellbeing incentives, high street discounts, plus much more!