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Discharge Enablement Facilitator and Admission Avoidance Supporter

Northamptonshire Healthcare NHS Foundation Trust
£33,706 to £40,588 a year per annum pro rata
Closing date
26 Sep 2022

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CBT Therapist / Other
Learning Disability
Band 6
Contract Type
Full Time
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This is a unique post which will sit within the Transforming Care Team that is innovative and energetic in its engagement with the Transforming Care Agenda. The Transforming Care Team is a community-based service that works collaboratively with IST (Intensive Support Team), CSRT (Community Swift Response Team) and CTPLD (Community Team for People with Learning Disability) and CMHT/CAMHS/ALMHS/NASS and Children's services - across all health and care service providers/care settings or place of care, for people with LD/ASD). The Transforming Care Agenda and our local Northamptonshire Health and Care Partnership is all about improving health and care services so that adults, children, and young people with a learning disability and/or Autism can live in the community with the right support.

We also provide health services to various prisons and detention centres in Bedfordshire and Cambridgeshire.

Main duties of the job

The focus of the Band 6 role will be to support not only short stayers in hospital but longer stayers, including out of area placements, and working closely with patients in hospital within a multidisciplinary environment to provide support within the context of an enablement approach and operating within an integrated service to provide individualised, outcome led personalised support, based on structured individual assessments to minimise or eliminate a service user's dependency on long term hospital care. The post holder will also conduct timely, regular and frequent reviews of people's support plans through the patient MDT, and constructively challenge plans that delay any discharge in the context of changing circumstances.

About us

NHFT is an integrated primary care and mental health Trust, providing physical, mental health and specialty services in both hospital settings and out in the community. Because we put the person at the centre of all we do, we focus on delivering care that is as easy to access as possible. This means many of our services can be provided at home, work or in schools.

Job description Job responsibilities

The primary role of this post is to work collaboratively with the discharge in mind of all clients/citizens within the cohort who are at risk of admission, in hospital or long stay facilities across all service providers and LD or mental health and Forensic Inpatient Services. The role will include chairing CTRs (Care and Treatment Reviews) and CETRs (Care and Education Treatment Reviews). The role involves collaborative working with the local CCG, providers, MAPPA, Prison service, NHSE/I Case managers other CCGs and Social Care and is a prerequisite that is central to supporting people with the transforming care cohort. You will work within a MDT in implementing person centred support plans for individuals and their families/carers. The focus will be on maximising independence and supporting the individual to remain in their own home, facilitating prompt discharge from hospital and supporting anticipatory care planning to prevent readmission to hospital. Attending professional, clinical, MDT meetings and CPAs countywide and out of area and working with the rest of the TCP team, social care and CCG in ensuring all statutory service options have been explored in supporting hospital discharges.

Using the MDT approach when working with all service providers, the Transforming Care Team will be the facilitator and enabler liaising with all stakeholders. An oversight of all patients within the cohort, AROAR and a leading assurance role with governance and knowledge of needs. The role will include teaching and facilitating education across all service providers and stakeholders to ensure appropriate responses to the Trust, the service and ultimately that the persons needs are being met, alongside the MDT and throughout the patients journey mapped against their care plan.

In liaison with Health and Social Care teams the role will support the local Transforming Care Agenda to prevent unnecessary inpatient admissions for people with a learning disability and/or autism, and to lead the assurance of high-quality contingency planning and written documentation and support practitioners through advice and coaching in promoting best practice in admission avoidance and risk management. This post is across the lifelong pathway in Learning Disability and mental health.

Lastly but not least, part of this role is to support admission avoidance/crisis management by being able to respond to crisis in the community with proactive, innovative and targeted responses to meet a persons needs. This will involve and include the patient, family, care providers, professionals and anybody else involved in meeting the individuals needs.

For further information on the advertised role, please refer to the job description located under the Supporting Documents heading. The full person specification can be accessed under the About You Section of the document.

Person Specification Behaviours and Values Essential
  • Ability to navigate and work through complex discharge pathways
  • Ability to challenge decisions, timescales, and pathway to enable discharge
Knowledge and Experience Essential
  • Educated to relevant degree level or professional qualification e.g., nursing, social work, allied healthcare
  • Knowledge and experience of working in a Learning Disability service/provider
  • Knowledge of the National Transforming Care Programme of work and Transforming Care Agenda
  • Knowledge and experience in Transforming Care
  • Specialist knowledge of learning disability, autism and behaviours that challenge
  • Knowledge of working in acute or community mental health units, mental health pathways and care planning
  • Learning Disability Nurse qualification
  • Experience of training/presenting to others
  • Experience of coaching/mentoring others
  • Experience of supporting services and commissioners to develop a life-long pathway of support and crisis avoidance
Skills and Abilities Essential
  • Have the ability to advocate for the service users and colleagues that you are supporting
  • Good presentation skills

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