Care Transfer Hub Practitioner

Role description

Job summary

The Care Transfer Hub Practitioner is responsible for navigating and coordinating flow across Joined Up Care Derbyshire services by managing referrals through the system Care Transfer Hub.

The post holder will take a lead role in assessing an individual's need, triaging referrals and using professional judgement to navigate and coordinate the support needs.

The role is pivotal in ensuring people are safely and appropriately transferred between care settings.

Working within a multi-agency Care Transfer Hub, the postholder ensures timely and appropriate onward referrals to community health, social care, or voluntary sector services.

This role involves clinical triage, multidisciplinary collaboration, and effective communication to avoid delays in hospital discharge and ensure continuity of care.

There may be the opportunity to work alongside colleagues within the acute hospital setting as part of the role.

THIS POST IS ONLY OPEN TO CURRENT JUCD EMPLOYEES - PLEASE ONLY APPLY IF YOU WORK FOR ONE OF THE FOLLOWING:

NHS Derby & Derbyshire ICB, Chesterfield Royal Hospital NHSFT, University Hospitals Derby and Burton NHSFT, Derbyshire Healthcare NHSFT, Derbyshire Community Health Services NHSFT, East Midlands Ambulance Service, Derby City social care or Derbyshire County social care (employees of DHU Healthcare will be considered).

Main duties of the job

Use experience and knowledge to triage and navigate the future ongoing needs for patients accessing intermediate care pathways from acute or community settings.

Work in both a multi-disciplinary and interdisciplinary way to develop timely and person-centred plans based on the home first principles.

Promote a strength-based approach to maintain independence and positive risk taking, ensuring adequate support is in place from statutory or voluntary services where required.

Liaise with health and social care professionals, including district nurses, social workers, therapists and care providers. Participate in, and lead, multidisciplinary meetings (MDTs) and contribute to discharge planning processes.

Support decision-making around Continuing Healthcare (CHC), reablement, and domiciliary care packages.

Act as a point of contact for professionals and patients/families regarding transfer of care.

About us

Working for our organisation

Our purpose is to provide community health services to a patient population of over one million people in Derbyshire and Derby, as part of Joined Up Care Derbyshire.

We employ around 4,200 substantive staff, caring for patients in 11 community hospitals and more than 30 health centres, as well as in clinics, GP practices, schools, care homes and, increasingly, in people's own homes and via virtual consultations.

It is an exciting time to join primary care and community services as the national Ageing Well programme gathers pace.

DCHS is working closely with the Primary Care Networks to transform the care of housebound and vulnerable people across Derbyshire through our Team-Up approach.