Community Transfer of Care Hub Case Manager

Are you a Nurse, Therapist or Paramedic passionate about supporting people to return to their own homes following acute illness or injury? Bristol NHS Foundation Trust have a Transfer of Care Hub at Weston General Hospital where the aim is to support patients with discharge planning from admission through leaving hospital and into the community. The Transfer of Care Hub brings together the Acute Trust, Community Partners (Sirona), Local Authorities and Voluntary Sector colleagues across BNSSG to support complex discharge planning. Sirona Community Transfer of Care Hub (CToCH) are the community experts in discharge planning working together with the Transfer of Care Hub partners to navigate patients to the most appropriate community discharge pathway. As a case manager you will need to have experience working in a community setting and an understanding of the levels of clinical acuity that can be supported in peoples own homes. Alongside this you will have an understanding of rehabilitation pathways, discharge planning and mental capacity issues, excellent interpersonal and negotiation skills. In return, we will provide you with regular training and supervision and enable you to become involved in future service developments. This role is based mainly in Cadbury Garden Centre Offices with inreach days into Weston General Hospital.,

• Be a key member of the multi-disciplinary team, responsible for providing person-centred, holistic assessment to facilitate discharge from the acute hospitals to the right discharge pathway.
• Responsible for triaging referrals received by CToCH. This may include liaising with the patient, family/carers and ward staff to identify the most appropriate discharge pathway.
• Support the CToCH to discuss complex cases with all partners in the Transfer of Care Hub to agree a joint action and discharge plan.
• To utilise multi-disciplinary assessment skills, supported by sound clinical reasoning to facilitate timely hospital discharge to the most appropriate environment
• To be able to effectively triage and prioritise a large caseload and be able to adjust daily work plan in response to system-wide pressures and escalation. Pro-actively optimising the usage of community capacity on a daily basis.
• High level of problem-solving required, gathering information from a range of sources, using professional experience and clinical knowledge to inform decision making. This includes being able to complete mental capacity assessments and make best interest decisions where appropriate.
  
  Professional Qualification in Nursing, Occupational Therapy or Physiotherapy. Registered with NMC, HCPC or RCN, Able to work across professional and organisational boundaries recognising when there are barriers to partnership working and able to implement solutions to overcome these
• The ability to interpret clinical information, use analytical and problem-solving skills to inform decision making
• Able to demonstrate innovative practice
• Ability to coordinate and manage a caseload including prioritising the workload, appropriate use of escalation plan, time management and delegation.
• When required to be able to present information to the CCG to support the requirement of additional funding (e.g., 1-1 support) to enable a hospital discharge
• Ability to complete mental capacity assessments when required and if the patient lacks capacity act as the lead for making a best interest decision as part of a multi-disciplinary team, Ability to present self and service in a professional manner promoting the service at all times
• Experience of working within hospital and community settings
• Ability to build, and maintain, effective working relationships at all levels, Ability to present self and service in a professional manner promoting the service at all times
• Experience of working within hospital and community settings
• Ability to build, and maintain, effective working relationships at all levels
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Ever dreamt about a career that sparks excitement and fosters your professional growth? Picture yourself waking up eager to make arealdifference in our community, surrounded by teams who value your unique ideas. We are Sirona care & health - England's largest provider of Adult's and Children's Community Services and we'd love for you to join us in Bristol, North Somerset or South Gloucestershire. Agenda for Change Salary, full NHS benefits, 27+ days' annual leave, and participation in the NHS Pension Scheme - just a glimpse of the benefits you'll receive. We welcome and encourage all applicants. We are committed to having a workforce that reflects the communities we support and are proactively seeking to improve the diversity of our workforce. We know diversity fosters creativity and innovation. We are committed to equality of opportunity, to being fair and inclusive, and to being a place where all belong. We aim to draw upon the widest possible range of views and experiences to meet the changing needs of our colleagues, partners and communities we serve. Whether you're starting your journey in healthcare, looking for a fresh challenge within the NHS, or contemplating a career change, don't be daunted by the prospect of something different - we create development opportunities forallour colleagues and apprentices.