Central and North West London NHS Foundation Trust
Complex Case Discharge Coordinator

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Job Overview
Ensuring patients' admission to hospital is as productive but as short in duration as possible. Focus will be on working with inpatient staff, the patient and carers as well as community services across health, housing and social care to expedite the patient's discharge from hospital. The expectation is that you will support the smooth flow for the patient along the inpatient pathway and the development and execution of a comprehensive discharge plan for people with often complex and diverse mental health and psychological needs.
Main duties of the job
- Work as a core member of the Older Adult Inpatient Clinical Team but also develop excellent working relationships with locality based inpatient MDT's, Crisis Teams, CMHT's, Housing Providers, 3rd Sector and Charitable Organisations and Adult Social Care Services.
- In conjunction with other professionals, identify current inpatients whose needs could best be met in a lesser restrictive environment e.g. in their own home with crisis/outreach support, in a respite or 'step-down' facility or in a residential/nursing care home setting.
- Work to develop comprehensive discharge plans for individuals with complex mental health and psychological needs, whose discharge from hospital could be expedited.
- To assess current risks and identify how the risk and patients' mental health needs would best be met.
- To provide information and advice to carers to support them through the crisis period.
- To have a sound understanding and knowledge of current legislation and its application to service users with mental health problems e.g. Mental Health Act, Mental Capacity Act (and DoLS), Community Care Act, Safeguarding Adults, Child Protection, Human Rights Act, Freedom of Information Act, Data Protection Act.
- Undertake collaborative actions with inpatient MDT's, Community Mental Health Services, Adult Social Care, Housing and 3rd Sector care providers, Service Users and their Carers/families to facilitate safe and timely discharge from hospital.
Working for our organisation
There’s a place for you at CNWL.
We’re passionate about delivering first-class patient-centred, safe and effective care, whether it is in a hospital setting, in a community clinic or in the patient’s own home. Patients are at the heart of everything we do.
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Providing top quality care depends on our ability to employ the best people.
We’re always looking to recruit outstanding people who will go the extra mile to support our patients, colleagues, teams and the Trust. With every new employee we’re hoping to find our future leaders and we’ll support our staff by providing opportunities to develop your career.
With a diverse culture and equally diverse range of opportunities across mental health, community services, addictions, eating disorders, learning disabilities and more – whatever stage of your career you're at, there's always a place for you at CNWL
Detailed Job Description And Main Responsibilities
- Work as a core member of the Older Adult Inpatient Clinical Team but also develop excellent working relationships with locality based inpatient MDT's, Crisis Teams, CMHT's, Housing Providers, 3rd Sector and Charitable Organisations and Adult Social Care Services.
- Contribute to locality and trust wide flow information and meetings.
- In conjunction with other professionals, identify current inpatients whose needs could best be met in a lesser restrictive environment e.g. in their own home with crisis/outreach support, in a respite or 'step-down' facility or in a residential/nursing care home setting.
- Work to develop comprehensive discharge plans for individuals with complex mental health and psychological needs, whose discharge from hospital could be expedited.
- To assess current risks and identify how the risk and patients' mental health needs would best be met.
- To build and maintain therapeutic relationships with patients and carers and involve them in drawing up discharge plans.
- To provide information and advice to carers to support them through the crisis period.
- To have a sound understanding and knowledge of current legislation and its application to service users with mental health problems e.g. Mental Health Act, Mental Capacity Act (and DoLS), Community Care Act, Safeguarding Adults, Child Protection, Human Rights Act, Freedom of Information Act, Data Protection Act.
- To organise and facilitate MDT meetings, Ward Rounds, Admission and Discharge Meetings.
- Undertake collaborative actions with inpatient MDT's, Community Mental Health Services, Adult Social Care, Housing and 3rd Sector care providers, Service Users and their Carers/families to facilitate safe and timely discharge from hospital.
- Working with the allocated social worker / care co-ordinator provide initial, time limited, post discharge input to patients who are discharged to residential/nursing care homes and other formal care settings.
- Sign-posting and direct referrals to appropriate community based services.


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Person specification
Education & Qualifications
Essential criteria
- RMN/Diploma/Degree
- Evidence of continued professional development In post-registration qualifications
Desirable criteria
- A post registration qualification in Older People
- RGN or other qualification in physical health
- Experience of working with dementia and of working with older adults
Experience
Essential criteria
- Post-registration experience in a range of clinical areas.
- Experience of working as member of a Multi –disciplinary team
Desirable criteria
- Experience of managing/supervision of staff.
- Experience of working with dementia
- Experience of working with Local Authority / Social Services
Knowledge
Essential criteria
- Knowledge of Risk Assessment and Risk Management Processes
- Knowledge and understanding of legislation relating to the care of Older Adults with Mental Health problems in the community
- Knowledge of ethical/legal requirements within mental health nursing.
- Knowledge and understanding of the needs and rights of service users and their carers.
Desirable criteria
- Knowledge of the Care Act and a willingness to become a Trusted Assessor
Skills And Abilities
Essential criteria
- Effective communication skills both verbally and through written reports
- Ability to assess complex risk and produce care plans to manage this
- Ability to take responsibility for managing a caseload
- Ability to manage complex decision making situations.
- Ability to reflect and critically appraise own performance
- Ability to work effectively in stressful and emotionally charged situation
Desirable criteria
- IT skills i.e. Microsoft word, Email, Internet
- Motivated and able to motivate others.
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