Job descriptionPLEASE SEE THE ATTACHED JOB DESCRIPTION FOR FULL DUTIES OF THE ROLE. Main Purpose of the Job: The post holder will work as a senior Coordinator for the Recovery at Home Team, based within the Hospital site and Community Site when needed. The post holder will need to work closely with key stakeholders within the Acute Trust and including all Community Services delivering a community driven, discharge to assess approach to discharge enabling the effective flow of people into the right service at the right time. Where necessary such as at the point of discharge from the virtual ward, the post holder should ensure good communication and joined up working is in place with the person's registered GP practice To work autonomously, assessing an individual patients needs, identifying people appropriate for Virtual Ward based care: determining a plan of care and initiating appropriate holistic, research-based health information and care. To work within agreed Trust Pathways of Care, ensuring safe, prompt and effective decision making. Lead and manage a Multi-disciplinary Team to ensure the day-to-day operational delivery of high-quality care for those patients admitted to the Virtual Ward. This role will include working across the wider health system to ensure the delivery of proactive management of this group of patients Work collaboratively with Multi-Disciplinary Teams to ensure practice is efficient, effective, evidence based and to help create clinical management plans to support patients to remain safely at home. To act as a resource for all members of the Multi-Disciplinary Team, providing expert advice concerning aspects of the persons management plan. Alongside the Virtual Ward team to deliver effective communication about the virtual ward patient with the person's registered general practice, ensuring that information is conveyed appropriately and supports delivery of a seamless care pathway As Virtual Ward Coordinator, you will ensure successful and timely onward transition to the next step in a persons pathway. The Virtual Ward Coordinator will use a problem- solving approach, working with members of the multidisciplinary team to facilitate effective discharges into the Virtual Ward, with a focus on a persons clinical and holistic needs working within the Virtual Ward pathways To work to ensure a seamless interface between acute colleagues identifying people medically fit for discharge, then ready to leave hospital. To contribute to the overall management and development of the service To lead, motivate and support the colleague's approach to delivering new and innovative models of care for people. To lead a continuously improving service, by ensuring systems are in place to support clinical governance, quality monitoring and ongoing research and audit of practice. Ensure systems and processes are in place to maintain patient safety. To be responsible for ensuring that agreed professional standards are reflected in practice and to have overall responsibility for monitoring the standard of care. To improve the patient journey by increasing access to assessment and appropriate care and treatment, by auditing and reviewing the Virtual Ward regularly Support the development and delivery of new national initiatives both in relation to, Virtual Wards Proactively plan for and enable timely discharge of patients from the Virtual Ward, liaising with other agencies to provide ongoing care if required The role may include caring for people and their relatives/informal carers who are anxious, confused or distressed and clear communication skills and empathy is required to offer reassuring and guidance. A part of each working day involves talking to patients either via the telephone, videocall or face to face. Provide a high-quality support service to patients on the Virtual Ward caseload. Promote the knowledge and understanding of the range of services available across organisations Act as a link person between the wider Virtual Ward team and other agencies, maintaining and promoting positive working relationships with all referring agencies Participate in the development of initiatives within the service If required, will manage staff including assuring completion of supervision, appraisals and compliance with mandatory training Oversee and delegate remote monitoring of patients across a variety of clinical pathways including respiratory and frailty Undertake clinical assessment of patients on the Virtual Ward and develop, implement and evaluate care and treatment plans. Use their advanced assessment skills to assess patients who are on the virtual ward, and whose observations taken via remote monitoring require further assessment and review face to face. Ensure there is an effective referral pathway for the Virtual Ward including initial triage. Referrals will be received The Virtual Ward Coordinator will support caseload management, ensuring that service delivery is implemented to the highest standard inclusive of best practice and utilises a patient centred approach. The Virtual Ward Coordinator will be a liaison and a single point of coordination for those readmitted to Hospital or stepped up to SDEC for investigations. The Coordinator will discuss the outcome of assessments with the clinical team and support, where possible a timely discharge back to the Virtual Ward. The post holder will provide patients with a physical health and biopsychological assessment and where necessary will complete frailty assessments for frailty patients. In partnership with the Frailty Team ensure monitoring of Clinical Frailty Score for all patients identified with frailty alongside a Comprehensive Geriatric Assessment. To work alongside Assistive Technology teams to ensure that all patients have access to tablet and a data connection. The post holder will demonstrate detailed knowledge of digital monitoring and be able to support patients with familiarising themselves with technology and monitoring devices such as BP or SP02 monitors.
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