Discharge Liaison Nurse Job Oxford area,England UK,Healthcare

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

To work towards a culture of reducing the number of avoidable admissions and delayed transfers of care, in partnership with primary and secondary care, 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 cantered 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 inpatients delayed transfer of care information focusing on longest stayers,

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 Social Services 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.
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 ToC team to identify appropriate discharge pathway and issue a Medically Optimised for Discharge Notice where the patient is agreed to be fit for discharge and necessary assessments complete
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 Community Hospitals to ensure that available beds are used as effectively as possible and occupancy is maintained at 100% wherever 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…