Community Transfer of Care Hub Case Manager
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We reserve the right to close this vacancy early if sufficient applications are received prior to the advertised closing date.
Job overview
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?
UHBW are launching two new Transfer of Care Hubs to support our patients with discharge planning from admission through leaving hospital and into the community at the Bristol Site and one at Weston General Hospital. The Transfer of Care Hub will bring together the acute trust, community partners (Sirona), Local Authorities and Voluntary Sector colleagues across BNSSG to create a new team from multidisciplinary backgrounds.
The aim is to work collaboratively to support patients to get Home First by collocating a team of professionals from different organisations to streamline complex discharges.
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!
You will join our dynamic Bristol team and be based in South Bristol Community Hospital.
Main duties of the job- 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.
- 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.
- Support the CToCH to discuss complex cases with all partners in the Transfer of Care Hub to agree a joint action and discharge plan.
- To utilise multi-disciplinary assessment skills, supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment
- To be able to 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.
- High level of problem-solving required, gathering information from a range of sources, 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
Ever dreamt about a career that sparks excitement and fosters your professional growth? Picture yourself waking up eager to make a real difference in our community, surrounded by teams who value your unique ideas. It's time to turn your dream into reality!
We are Sirona care & health – England’s largest provider of Adult’s and Children’s Community Services and we’d love for you to join us in Bristol, North Somerset or South Gloucestershire.
Agenda for Change Salary, full NHS benefits, 27+ days’ annual leave, and participation in the NHS Pension Scheme – just a glimpse of the benefits we offer.
Whether you're starting your journey in healthcare, looking for a fresh challenge within the NHS, or contemplating a career change, don't be daunted by the prospect of something different – we create development opportunities for all our colleagues and apprentices.
Interested? View our benefits leaflet which you can find as an attachment on this vacancy.
Detailed job description and main responsibilities
Please see the job description and person specification attached for further information on the role.
We are unable to provide sponsorship for this role and can only accept applications from UK based applicants.
If you are currently require a visa to work in the UK, there must be a minimum of 12 months from your start date until the expiry date.
Person specification
Qualifications
Essential criteria- Professional Qualification in Nursing, Occupational Therapy or Physiotherapy. Registered with NMC, HCPC or RCN
Skills, knowledge and experience
Essential criteria- Able to work across professional and organisational boundaries recognising when there are barriers to partnership working and able to implement solutions to overcome these
- The ability to interpret clinical information, use analytical and problem-solving skills to inform decision making
- Able to demonstrate innovative practice
- Ability to coordinate and manage a caseload including prioritising the workload, appropriate use of escalation plan, time management and delegation.
- When required to be able to present information to the CCG to support the requirement of additional funding (e.g., 1-1 support) to enable a hospital discharge
- Ability to complete mental capacity assessments when required and if the patient lacks capacity act as the lead for making a best interest decision as part of a multi-disciplinary team
- Ability to present self and service in a professional manner promoting the service at all times
- Experience of working within hospital and community settings
- Ability to build, and maintain, effective working relationships at all levels
Location Preference
Essential criteria- Please advise within your supporting statement, your preference of location; South Bristol Community Hospital (BS14 0DE) or Castlewood (BS21 6FW)