Clinical Lead Transfer of care Hub

Have responsibility for the facilitation oftimely and safe discharges/transfers from hospital.

Provide effective communication to ensure that ward discharges occur ina timelyandwell-plannedmanner liaising with patient, carers, ward staff,multi-disciplinaryteamand community partners.

Challenge practice and explore new ways of working with partner organisations

Work with a defined case load and prioritise care from admission to discharge

Act as a resource for all clinical area's related to discharge planning

To deputise for the Complex Case Managers

Participatein the development of nursing and medical staff in all aspects of discharge planning, To be proactive in the management of the patient's journey to improve and reduce length of stay Tofacilitaterobust discharge plans/act as a resource for ward staff that enable patients who are assessed as medically fit to be discharged ina timely and safe manner. Toidentifycritical delays in the entire diagnostic,treatmentand care processes and to be proactive in generating solutions that will speed up process.

To support development of a culture within the Trust where discharge planning begins at first contact with patients on admission through formal and informal teaching sessions.

Organise familymeetings and be the lead with allpossible attendeesincluding patients,familiesand external agencies as well as internal.

Toidentifypatients suitable for rehabilitation or for step down area beds asrequired

To work in conjunction with ward multi-professional teams, Social Services and Community partners to proactively manage discharge planning forfacilitatinga timelyand safe discharge from hospital for the patient.

To liaise with multidisciplinary team to highlight any delays in patient pathway on specific ward areas. Tomaintaineffective communication with community partners to ensure continuity of care and safe, effective discharge planning.

To provide advice to ward staff/clinicians on progressing safe andappropriate dischargefor those patients who have complex needs.

We operatefrom three main hospitals-Furness General Hospital (FGH) in Barrow, the Royal Lancaster Infirmary (RLI), and Westmorland General Hospital (WGH) in Kendal, as well as a number of community healthcare premises including Millom Hospital and GP Practice, Queen Victoria Hospital in Morecambe, andUlverstonCommunity Health Centre.

FGH and the RLI have a range of General Hospital services, with full Emergency Departments, Critical/Coronary Care units and various Consultant-led services.

WGH provides a range of General Hospital services, together with an Urgent Treatment Centre, that can help with a range of non-life threatening conditions such as broken bones and minor illnesses.

All three main hospitals provide a range of planned care including outpatients, diagnostics, therapies,daycase and inpatient surgery. In addition, a range of local outreach services and diagnostics are provided from community facilities across Morecambe Bay.

Our Community Service for adults are provided in people's homes ,community centres, clinics, GP Practices, community hospitals. Our aim is to work with people to help them remain independent , improve their health and manage their conditions through high quality care , advice and support.