Pathway Facilitator

NCH&C is proud to be the first standalone NHS community trust in the UK to achieve an 'Outstanding' rating from the Care Quality Commission (CQC). Our focus is on continually improving the quality of care we offer to local people and on improving access to that care, helping people to move seamlessly from one service to another. Praising NCH&C's "compassionate, inclusive and effective leadership at all levels", the CQC observed that our staff are well supported to make positive changes and innovations.
Norfolk Community Health & Care NHS Trust is committed to continuing to create a modern and inclusive work environment. As part of this commitment we actively promote flexible working opportunities where possible, to meet the needs and wishes of our workforce to maintain and improve their wellbeing. The trust offers a range of flexibility, including flexible working patterns, and we would encourage you to discuss this with the recruiting manager before or during the application process if this would interest you.
We welcome applications from people who share our values and can help us deliver outstanding care in our local community., Co-ordinate admissions and discharges of patients admitted to the Specialist Palliative Care in-patient unit (PBL) working closely with the Palliative Care Coordination Centre.
Liaise closely with Health and Social Care across Norwich, South and North localities and Acute Trusts to ensure smooth, timely and coordinated admissions/discharges, transfers of care and discharges based on patient need and choice.
Work with the multidisciplinary team, identify the need for development in the present processes and proactively work towards improving flow of patients and preventing delay in discharge., Co-ordinate admissions and discharges of patients admitted to the Specialist Palliative Care in-patient unit (PBL) working closely with the Palliative Care Coordination Centre.
Liaise closely with Health and Social Care across Norwich, South and North localities and Acute Trusts to ensure smooth, timely and coordinated admissions/discharges, transfers of care and discharges based on patient need and choice.
Work with the multidisciplinary team, identify the need for development in the present processes and proactively work towards improving flow of patients and preventing delay in discharge.
Read the attached job description and person specification file for more information., 1. To facilitate admission and discharge of patients ensuring high quality holistic and individualised care to patients and their families.
2. To ensure patient-centred and clinically effective service.
3. To participate in developing joint action plans, protocols and pathways and influence the use of these.
4. To work in line with protocols and pathways with appropriate information which prioritise palliative care patients and address the particular needs of this vulnerable group of patients.
5. Work closely with Trust colleagues in continuing care to design appropriate packages of care.
6. To facilitate patients being discharged into a virtual bed.
7. Work with the multidisciplinary team in order to provide a patient focused service ensuring smooth planning, co-ordination and communication between primary, intermediate and secondary services in order to facilitate seamless care.
8. To work in partnership with the referrals/triage team, medical, nursing, social worker and allied health professionals..
To be aware of local arrangements for health and social care, intermediate, primary care and community services. (It is increasingly evident that effective hospital discharges can only be achieved when there is good joint working between the NHS, local authorities, housing organisations, primary care and the independent and voluntary sectors).
Undertake assessments of patients and carers, identifying their psychological, social, practical and spiritual needs in accordance with NICE guidelines, demonstrating and applying knowledge of the options for discharge in order to develop a discharge plan to meet their needs.
. To start planning the patient's discharge within 24 hours of the patient's admission using the discharge tool within the integrated notes.
1To ensure individuals and their carers are actively engaged in the planning and delivery of their care.
1To liaise with ward staff, pharmacy regarding organisation of TTOs.
1To attend daily MDT handovers and Central Referral meetings as required.
. To be responsible for making follow-up calls within 24 hours after discharge to patients and their families as necessary documenting the outcome in the notes.
. To escort patients in transfers of care as necessary.
Ensure open, honest and effective communications are maintained in order to facilitate joint working practices around integrated patient pathways for transfer or care.
To work in conjunction with all agencies to provide the appropriate equipment for discharge.
To liaise with the Ward Manager on all day-to-day issues re admission/discharge within the SPC in-patient unit.
To demonstrate skills to maintain, encourage and enhance effective communication between all agencies.
To actively listen and communicate appropriately in difficult and complex situations.
To maintain clinical competencies and work within the ward team as directed.
To deliver high quality, compassionate and effective care.
To ensure the administration of drugs and therapeutic substances are given in accordance with legal and NMC requirements.
Management Responsibilities
1. Understands SPC philosophy/operational policy/service specification.
2. To promote and enhance collaborative working through the use of reflective practice.
3. To take remedial action to diffuse complaints and potential complaints from patients and/or their relatives/carers thus maintaining good relationships between the service and service users.
Education
1. To maintain personal development fulfilling all requirements of PREP and the organisation.
2. To update and develop own clinical/theoretical knowledge relating to the specialty and other areas of nursing to ensure care is innovative, research based and of a high standard.
Audit, Research & Development
1. To critically analyse the relevance of appropriate research related to practice and allow this to influence and alter own practice as appropriate.
2. Is critically aware of the range of research approaches that can be used to develop knowledge from practice.
3. To review causes of delays in discharge, liaise with relevant staff within and outside the hospital, patients, relatives and carers.
4. To participate in audits and research pertinent to admissions/discharge planning.
To record accurate statistical data and information
Read the attached job description and person specification file for more information.
Equal Opportunities - We are an equal opportunities employer and welcome all applications irrespective of age, disability, gender, sexual orientation, race or religion. Additionally, people with disabilities that fall under the Disability Confident Scheme will be offered an interview providing they meet the minimum criteria for the post (outlined in the Person Specification). All sites are Smoke Free.
Immigration Status - Norfolk Community Health & Care NHS Trust is a diverse employer and welcomes all job applications. However, potential applicants should note that although the Trust is registered with the Home Office as a sponsor organisation for migrant workers, sponsorship can only be offered against Skilled Worker visas. If you are an applicant from outside the UK and do not already hold a self-gained right to work, we recommend you check the Home Office eligibility requirements before making an application.
Please note: Although we are a registered sponsor organisation, we are unable to offer sponsorship for some job roles, and this will be identified through filtering questions at the start of any job application on the Trac recruitment system.
Redeployment - Please note that in the first instance priority for this vacancy will be given to NCH&C staff who are on the Trusts Redeployment Register.
DBS - If this post is subject to a Disclosure and Barring Service (DBS) check and you are not a current employee of Norfolk Community Health and Care NHS Trust or being recruited as an Apprentice then the cost of the DBS check will be automatically removed from your first month's salary. However if you are registered with the update service this may not be required.

Please note, the selection processes at Norfolk Community Health and Care NHS Trust are in place to ensure we recruit candidates with the right values and skills, please be advised that the use of AI in applications are monitored. We remain watchful of candidates who misuse these tools to generate an application that doesn't accurately reflect their skills., On April 1st 2025, the Boards of Norfolk Community Health and Care NHS Trust and Cambridgeshire Community Services NHS Trust will come together to deliver services as a group, with a singular board operating across both organisations. Both trusts are high performing specialist community health and care providers working in the East of England. Both have a strong track record, with the highest ratings from the Care Quality Commission, best in class NHS staff survey outcomes, and a decade of experience in innovation and clinical development.
The group model provides health and care services to a population of 3.2 million in their homes and neighbourhoods. We provide care that supports people from the very beginning to the very end of their lives.
We will remain two separate employers until further notice, and this role being advertised will be employed by Norfolk Community Health and Care NHS Trust.