An exciting opportunity has arisen for a Band 7 Clinician to join a new Transfer of Care hub, coordinating care for Service Users who are in the most acute phase of a mental health crisis. The role will involve overseeing a Service User’s journey from admission to discharge, ensuring that the flow throughout this critical part of their treatment is seamless and purposeful.
You will join a team that aims to use system knowledge and clinical skills to optimize each patient’s outcome and recovery. BNSSG Transfer of Care (TOC) hub is a fast paced and ever evolving environment. You will need to be able to work flexibly and collaboratively both within the TOC team along with internal and external stakeholders.
We are looking for an enthusiastic, highly motivated and dynamic individual who will work closely with the Crisis Teams to review admission requests and ensure Service Users are receiving the right care in the most appropriate setting, for example home treatment or inpatient admission.
The post holder will work closely with the out of trust placement manager to have clinical oversight of the BNSSG service users who are currently receiving care outside of AWP.
Clinically over see the care of service user in hospitals outside AWP.
Participate in daily bed calls in order to insure out of area service users are linked in with local services and discussed daily.
As part of the MDT the post holder will identify service users care needs, making recommendations regarding these care needs and assess clinical risk as required.
The post holder will need to be able to bring together stakeholders, with differing viewpoints and priorities, to reach consensus on individual discharge plans.
Lead the co-ordination of service user care in complex cases, discharges or transfer as appropriate, ensuring both health and social care needs are fully assessed.
Recognising when problems may occur and initiating an escalation to the service manager and Out of trust placement manager in a timely manor.
Build a working relationship and understanding of roles with in system partners.
To have an understanding of all clinical TOCH roles in order to deputies for each other.
Contribute to the development of policies and procedures within the TOC Hub
Maintain adequate records as required by existing procedures, entering appropriate details on Service User’s case notes as necessary, show a willingness to attend training to facilitate recording information electronically.
We are AWP (Avon and Wiltshire Mental Health Partnership NHS Trust): a diverse organisation with over 5,000 dedicated staff providing inpatient and community-based mental health care.
We provide services from a range of locations to approximately 1.8 million people living in Bath and North East Somerset (B&NES), Bristol, North Somerset, South Gloucestershire, Swindon, across the county of Wiltshire and in parts of Dorset.
Our outstanding people promote mental health and wellbeing. The expertise and resources within AWP are dedicated to a person-centred approach for those who use our services and for all employees. We recognise that happy and fulfilled employees give better care.
AWP is committed to support and create a positive research and evidence-based environment and culture, which can have a beneficial impact on everyone who works for the organisation and the care we provide to those who use our services.
At AWP we actively encourage applicants from all backgrounds; we are particularly keen to encourage applications from people from Black, Asian and minority ethnic backgrounds, those with disabilities and from the LGBTQ+ community. We want people to bring their unique blend of experiences, backgrounds, perspectives and knowledge to AWP, as diversity makes us stronger.
The post holder will coordinate the care and discharge of service users back in to the community supporting system flow and effective care by ensure Service Users are receiving the appropriate care, liaising with both the community teams and inpatient wards. This will not only enhance patient experience by ensuring a safe and efficient discharge from hospital but also support wider flow across the organisation.
The post holder will be required to attend and chair professional meetings regarding complex admissions where the pathway is not clear to ensure the right care is offered at the right time and ensure flow is achieved across our inpatient wards.
The post holder will be required to escalate any high-risk cases or barriers to care to both the Service Manager and out of trust placement manager in a timely manor.
The post holder will provide a pivotal role in managing out of area flow during an inpatient admission to reduce the number of delayed transfer of care cases. Through effective discharge planning, a multidisciplinary approach to continuity of care , a process that includes identification, assessment, goal setting, planning, implementation, coordination, and evaluation on or pre admission, to achieve a safe and timely discharge.
The post holder will be a health or social care professional with expertise of working within Mental Health services.
The post holder will build working relationships with inpatient and community teams along with relevant stakeholders including out of private care providers and Approved Mental Health Professionals and will be expected to attend regular meetings to support flow through the system

Please refer the Job description for details