Detailed job description and main responsibilities

Integrated Discharge Team

Work collaboratively with a range of multidisciplinary and organisational teams across both hospital and community settings.

Facilitate safe and timely discharge for patients receiving End-of-Life care and those requiring Department of Health Fast Track or 100% Continuing Healthcare funding.

Promote clear and effective communication between patients, relatives, carers and professional colleagues to ensure seamless care delivery, including the exchange of sensitive clinical information.

Support effective information sharing across organisations to maintain continuity of care throughout the patient journey.

Represent community services at multidisciplinary meetings and case conferences.

Enable and empower patients and their families/carers to participate in discharge planning, promoting independence, choice and informed decision-making.

Assess and prescribe equipment required for discharge to promote patient safety and support effective care delivery within the community.

Provide clinical supervision and participate in regular one-to-one sessions with delegated members of the team.

Recognise and manage challenges associated with cross-boundary working, particularly in relation to patients with complex needs and multiple care pathways.

Contribute to the GP Liaison Service by receiving referrals for same-day assessment within the Acute Trust and managing these effectively, with a focus on avoiding unnecessary admission where appropriate.

Ensure that all patients are treated with dignity, compassion and respect at all times.

Rapid Response

Prevent avoidable hospital admissions through comprehensive assessment, care planning, implementation, treatment and evaluation of care packages tailored to individual patient needs, in accordance with Trust policies and guidelines.

Support admission avoidance by assessing, coordinating and delivering specialised care packages for patients.

Undertake a range of core nursing interventions, including intravenous antibiotic administration, wound care, clinical observations, pressure area care and risk assessments such as PURPOSE-T and MUST.

Undertake advanced clinical procedures including intravenous therapy, cannulation, syringe driver management and catheterisation.

Perform diagnostic procedures and tests, where competent, to gain a comprehensive understanding of a patient’s condition, including ECGs, phlebotomy, blood glucose monitoring, Point of Care Testing and interpretation of blood results.

Prescribe medication, where appropriately qualified and authorised, in accordance with independent nurse prescribing standards and professional guidelines.

Work autonomously, using advanced clinical skills and nursing knowledge to assess, plan and deliver episodes of care, referring to other services where appropriate to support patient outcomes.

Facilitate effective communication between patients, relatives, carers and professional colleagues to ensure coordinated and seamless care.

Respond to urgent referrals from health and social care professionals, using sound clinical judgement and triage skills to assess, plan and implement evidence-based interventions.

Gather, analyse and interpret information from referrers, making informed decisions and advising on the most appropriate care pathway for the patient.

Assess and prioritise unscheduled requests for nursing intervention, ensuring allocation to the most appropriately skilled clinician.

Ensure that all patients are treated with dignity, compassion and respect at all times.

Be accountable for the holistic assessment, planning, implementation and evaluation of patient care packages and treatment interventions.

Identify and manage complications associated with patient care, implementing interventions that support patients to remain safely at home wherever appropriate. Maintain accurate and contemporaneous records.

Refer patients to other services and agencies as appropriate, including Social Services and specialist teams.

Recognise and escalate unforeseen crisis situations relating to staffing, caseloads, support networks or supervision, escalating risks, actions and outcomes to senior colleagues/team members as required.

Manage personal workload and support team workload management to ensure effective delivery of community care and reduce inappropriate hospital admissions.

Coordinate and oversee complex packages of care involving multiple professionals and agencies, providing specialist advice to patients and families to support informed decision-making.

Take responsibility for maintaining and developing the clinical skills and knowledge required to support safe care for patients on the caseload.

Participate in maintaining standards of care within the team, supporting the teaching, coordination, deployment and supervision of staff in accordance with their skills, knowledge and development needs. Participate in workforce planning, including annual leave, sickness and study leave cover, where required.

Be accountable for the effective management, prioritisation and delegation of work for both self and team members. Develop personalised, evidence-based care plans and ensure care is delivered by the most appropriate member of the multidisciplinary team.

Provide education and health promotion to patients and carers regarding their condition, treatment, potential side effects and expected outcomes, encouraging self-management, independence and resilience.