Age UK Herts Better at Home Team Manager

at  Watford Three Rivers Trust

BACKGROUND

In view of the winter pressures, workforce challenges and increased pressure on Acute Hospital services to manage the backlog, with specific focus on long waiters. We are seeking to scale up two approaches that have been successfully trialled in West Hertfordshire Hospital Trust (WHHT), which both support this agenda, align to existing resources in the community and further develop our community resource and support offer.
The two projects are Waiting Well, which supports a cohort of patients identified by the trust on a long waiting list with community support. The second is Discharge Support, focusing on a) telephone follow up to 65+s discharged on pathway zero and b) 2 weeks wraparound care for patients on other pathways who need non-clinical help to build resilience once home, again utilising the support available in the community to reduce readmissions.
Both Hertfordshire and West Essex have important infrastructure to support this work, including HertsHelp and the Hospital and Community Navigator Service (Herts) and Frontline and Live Well Link Well in West Essex, creating strong networks
This post requires some minimal travel within Hertfordshire

PURPOSE OF THE BETTER AT HOME TEAM MANAGER

The Better at Home Team Manager will contribute to the reduction of hospital readmissions by ensuring the personalised care offer from social prescribing is fully utilised, by building on the following pilots: This role will be split into two functions, one focusing on Waiting Well and one on Discharge Support

• The Enhanced Hospital Discharge Two Week Wrap-Around Service currently provided countywide in Hertfordshire
• The Pathway Zero pilot in Herts funded through Hertfordshire County Council to March 23 via HertsHelp whereby all patients over the age of 65 receive a call following their discharge from Hospital at 24 hours, with a follow up call at 5 days as appropriate.
• Waiting Well which supports a cohort of patients identified by the trust on a long waiting list with community support.

KEY RESPONSIBILITIES

• Managing the Team Leaders for Pathway 0 and Waiting Well as well as the Data Officer
• Attending HCNS managers meetings
• Developing consistent and effective referral processes and sharing of lists
• To ensure full awareness in the trust of the community and voluntary sector offer and enhance and develop systems to strengthen existing referral pathways, as well as to capture learnings from users experience of discharge.
• Sustainable systems are put in place for the future to make this part of how the hospitals continue to work, post March 2023
• Contribute to the development of targets
• Ensuring Data Officer maintains database, outcomes and reporting
• Monitor progress toward targets and where necessary recommend corrective action to ensure that targets are achieved
• Improving data sharing improved in line with appropriate Information Governance regulations

GENERAL RESPONSIBILITIES

• Work within agreed procedures, regulations, and systems, including for accounting, expenses, communications, data collection, monitoring, and quality assurance.
• Establish and maintain professional and supportive relationships with colleagues and with local groups.
• Undertake such other work as may reasonably be required from time to time including weekend working