Discharge Liaison Nurse

at  Oxford University Hospitals NHS Foundation Trust

The Discharge Liaison Nurse Team is excited to advertise a rare opportunity for an experienced nurse to join us to provide support various wards in John Radcliffe Hospital. The post holder aims to facilitate effective, efficient and timely discharge of patients from hospital.
As a member of this creative team you will be required to assess (in conjunction with the wider multi-disciplinary team) the health and social needs of patients and make recommendations for their onwards care provision.
Each patient varies according to need and therefore it is paramount that you can be flexible in how you anticipate the delivery of care and that you are able to think with and support patients/families/carers to achieve their own individual positive outcomes.
Communication is an area of utmost importance to ensure all relevant parties are aware of plans and you may be exposed to sensitive, difficult conversations where there are disagreements.
Information sharing between organisations is key; therefore the applicant should be able to maintain and share concise records using a number of different computer systems.
We are a busy team often working away from Base and so the post holder will need to feel comfortable with a high level of autonomy and be both skilled at managing conflicting priorities as well as confident in their practice.
To take the lead in ensuring patients are safely discharged
Provide advice and support to ward staff. To ensure that staff gain and maintain appropriate skills and competencies to manage simple and complex discharge needs on a daily basis.
To identify delayed discharges and inform relevant partners of the most urgent in priority order, and by use of specialist nursing knowledge, challenging inappropriate decisions.
To convene and ‘chair’ multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
To work with ward staff to ensure patients have up to date, realistic discharge plans and take action either personally or through delegation to implement, monitor and amend the plans if necessary.
To ensure ward staff refer patients, in a timely manner.
Lead and advise in the training and education of all staff in Discharge Planning.
Co-manage discharge coordinators
Liaise with the Single Point of Access and Community Hospitals to ensure that available beds are used as effectively as possible
To act as advocate and support for patients/carers/relatives to improve their experience and discharge from hospital
Represent the Trust in health and social care discussions relating to patient transfer / discharge processes, forging links with external agencies to improve practice.
Maintain a ‘Ready List’ of inpatients detailing their discharge plans
Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. Find out more here www.ouh.nhs.uk
The Trust comprises four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury.
Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call this Delivering Compassionate Excellence and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence. These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via the OUH YouTube channel .
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JOB SUMMARY:

The post holder aims to facilitate effective, efficient and timely discharge of patients from hospital. Particular emphasis is placed upon complex multi-disciplinary assessments including patients with complex health and social care, palliative care or rehabilitation needs.

DATA QUALITY

Data quality is a vital element of every member of staff’s job role. The Oxford Radcliffe Hospitals recognises the importance of information in the provision of patient care and in reporting on its performance. Data quality is therefore crucial in ensuring complete, timely and accurate information is available in support of patient care, clinical governance, performance management, service planning, and financial and resource planning and performance.
All staff should ensure that they have read and understood the Trust’s Data Quality Policy
This job description is intended as a guide to the duties and responsibilities of the post and should not be regarded as a complete list of those required to be fulfilled under the written statement of the main terms and conditions of employment. The contents may be amended from time to time subject to developing service needs, although such amendment would occur following appropriate consultation with the post holde

JOB PURPOSE:

• To work towards a culture of reducing the number of avoidable admissions and delays once patients no longer meet the criteria to reside, in partnership with primary and secondary care, community and social services and voluntary organisations.
• To work across professional boundaries, maintaining positive communication links between community and secondary care staff, social services, private and voluntary sector workers and allied health professions to promote collaborative working.
• To ensure that patients have an up to date discharge plan commenced on admission, which is patient centered and carried out in a timely manner, taking actions to reduce any potential delays.
• Provide advice to all partners with a ‘key relationship’ and patients/carers/relatives on progressing safe and appropriate discharge and the services available to support this
• To promote an ethos of admission avoidance through use of ambulatory pathways.
• To be involved in developing and maintaining discharge documentation and audits.
• To provide education and support to ward staff in clinical settings on current legislation, discharge planning, and NICE guidance.
• To design, develop and deliver appropriate training packages.
• To be involved in the collection and presentation of data for those patients who are medically optimised for discharge or with an extended length of stay
• To co-manage the Discharge Coordinators

KEY RESPONSIBILITIES:

To take the lead role in ensuring that patients are safely discharged from hospital
Provide expertise, advice and support to ward and care home staff. To ensure that staff gain and maintain appropriate skills and competencies to manage simple and complex discharge needs on a daily basis, and to reduce delay.
To identify patients whose discharge is delayed and inform relevant system partners of the most urgent in priority order, to positively influence funding decisions, and by use of specialist nursing knowledge, challenging inappropriate decisions.
If delays occur, identify causative factors and seek solutions to them in partnership with clinical teams.
Attend relevant meetings with system partners
To convene and ‘chair’ multi-disciplinary meetings, case conferences and best interests meetings setting goals for discharge planning.
To work with ward staff to ensure patients have up to date, realistic discharge plans and take action either personally or through delegation to implement, monitor and amend the plans if necessary in partnership with all relevant personnel.
To ensure ward staff refer appropriate patients, in a timely manner, to the Transfer of Care Hub
Lead and advise in the training and education of all staff in all aspects of Discharge Planning and further relevant developments either in a group setting or on an individual basis
Co-manage discharge coordinators to ensure they are efficient and effective in their role
Liaise with the Single Point of Access, Short Stay Hub Beds, and Community Hospitals to ensure that available beds are used as effectively as possible
Maintain accurate and comprehensive documentation and patient records either written or IT based in line with both Trust policy and NMC guidelines.
Work collaboratively with the Health and Social Care Economy to appropriately place patients
To initiate and design clinical audits of discharge planning and act on findings making recommendations on change to hospital discharge practice
To adhere at all times to trust policies for the protection of vulnerable adults
To act as advocate and support for patients/carers/relatives to improve their experience and discharge from hospital
To be aware of both national & local issues related to Discharge Planning- NICE Guidance, Continuing NHS Funded Care, Care Act 2014, Mental Capacity Act 2005 and the National Discharge Policy
Represent the Trust in health and social care discussions relating to patient transfer / discharge processes, forging links with external agencies to improve practice.
To maintain and update the Trust’s Discharges Intranet Site
Implement and uphold the Oxfordshire Protocol of Choice
Maintain a ‘Ready List’ of inpatients detailing their discharge plan

Communication & Working Relationships

• Ensure good communication with patients, their carers, nursing and medical colleagues, Social Services and other statutory and voluntary organisations.
• To provide support, help and advice to families, relatives / carers through the provision of appropriate information
• To report and record incidents/accidents in accordance with Trust Policy.
• Maintain confidentiality of information consistent with legislation.
• Maintain legible and comprehensive records.
• Create opportunity for people to communicate effectively.