Community Transfer of Care Hub Case Manager

Are you a nurse or therapist looking for a community job in a developing service? Are you passionate about supporting people to return to their own homes following acute illness or injury? UHBW are launching two new Transfer of Care Hubs to support our patients with discharge planning from admission through leaving hospital and into the community: One Hub at the Bristol Site and one at Weston General Hospital. The Transfer of Care Hub will bring together the acute trust, community partners (Sirona), Local Authorities and Voluntary Sector colleagues across BNSSG to create a new team from multidisciplinary backgrounds. The aim is to work collaboratively to support patients to get Home First by collocating a team of professionals from different organisations to streamline complex discharges. You will need to have experience working in the 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!,

• 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.
  
  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. It's time to turn your dream into reality!
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 we offer. 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.