Job summary

Band 6 Senior Nurse: Referral and Assessment Team

This is a great opportunity to work as part of the newly implemented Referral and Assessment Team, to support and co-ordinate a seamless transition of patients from Secondary care into Community services.

The post holder will be based in East Ham Care Centre and also spend some time with the Integrated Discharge Hub (IDH), working as part of a multidisciplinary and multi-agency team and in collaboration with other services to facilitate the timely referrals, and prompt, initial assessments of patients.

The successful post holder will be responsible for the assessment of patients that are medically optimised for discharge to ascertain their care needs and make referrals for ongoing patient care in the community, to facilitate a safe and effective discharge from the acute trust in a timely manner.

The Referral and Assessment Team works with patients and families with complex needs and conditions, supporting them in the discharge process in order for a smooth transition in to the community.

The Referral and Assessment Team provides guidance and professional support to the patient and the patient's families, and works with them in partnership to make sure the patient gets the most appropriate plan in place for discharge, whilst ensuring that interventions are not duplicated. This process improves the quality of care as well as improving patient satisfaction.

Main duties of the job

• Undertake comprehensive health care needs assessment of patients, reassessing as appropriate, working flexibly between the acute hospital and community locations.
• Assess, plan, prioritise, implement and evaluate nursing interventions to meet patients' needs.
• Undertake assessments for patients in the community and utilise assessment skills.
• Be responsible for case managing patients who are medically optimised for discharge including all relevant capacity and nursing assessments.

• Be responsible for assessing and planning the care for clients who may be approaching the end of their lives seeking packages of care via the appropriate process.
• Identify and refer those patients requiring intermediate care.
• Contribute to the organisation of multi-disciplinary, patient centred care.
• Facilitate patients, relatives and carers to take an active role in care giving, providing information as appropriate to facilitate independence where appropriate.

• To identify and assess patients for the supply of any appropriate equipment to ensure continuity of care is maintained.
• Attend and represent the Referral and Assessment Team in meetings in relation to provision of complex care packages and NHS continuing health care when required.

Previous applicants for this post in the last 3 months will not be shortlisted.

About us

The Referral and Assessment Team support patients with complex healthcare needs, who may require long-term health and social care planning or a short term intervention following a change of condition or acute illness.

The successful post holder will provide and/or arrange appropriate support and interventions in the community working closely with colleagues across all sectors and Newham Rapid Response Services.

They will work flexibly, interchanging between hospital and community working as required providing the full service cover.

The role requires working as an integral part of the team to provide specialist assessment skills, knowledge and management of patients in the community whilst ensure the delivery of outstanding, high calibre care, and efficient use of facilities, manpower and other resources.

Job description

Job responsibilities

Please could you kindly refer to the job description and person specification attached to this vacancy.

For contact details please see below.

Person Specification

Education and Training

Essential

• RGN with a valid NMC registration/Occupational Therapist/Physiotherapist with a valid HCPC registration
• Limited Prescriber or a willingness to undertake course (RGN)
• Advanced Physical Assessment Skills or willingness to undertake course
• Evidence of continuing professional education and training at degree level

Experience

Essential

• Relevant professional experience
• Evidence of professional development
• Evidence of recent clinical practice
• Knowledge of NMC/HCPC Code of Professional Conduct and Scope of Practice

Knowledge and Skills

Essential

• Evidence of leadership, change management and motivational skills
• Knowledge and understanding of current health and social care policy, i.e. National Service Frameworks
• Knowledge of evidenced based practice, i.e. NICE guidelines on Pressure Ulcers, Palliative Care and RCN guidelines Leg Ulcer Management
• Knowledge of principles of Clinical Governance

Any attachments will be accessible after you click to apply.

363-CHN11690-F