Job summary

We are looking to recruit individuals to manage a designated number of Transfer of Care patients. This role involves conducting initial assessments, developing care plans, and making onward referrals, while seeking support from senior clinicians when necessary.

You will be responsible for planning and executing daily tasks within the team and across a broader geographical area, understanding that these may shift in response to service demands and evolving clinical needs.

This position requires collaboration within a multidisciplinary team in a primary care setting, which includes clients' homes, residential facilities, and clinics. You'll provide support for a range of therapeutic and clinical interventions, drawing on the diverse skills within the team.

You will play a key role in promoting integrated working with partner systems and services, including Falls, UCR, and Virtual Wards. Additionally, you'll coordinate with multiple agencies to ensure effective and timely discharges.

A significant aspect of this role involves working autonomously in the community, using your own vehicle, and engaging in lone working. You will also assist with in-reach processes into Bedfordshire Hospitals.

Lastly, flexibility is essential, as the position requires you to work various shift patterns, including weekends and bank holidays on a rotational basis.

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Main duties of the job

• To participate in team planning, by organising new referrals as to who needs to be assessed within an agreed service time frame, and on-going work allocations, to enable the team to work effectively and efficiently whilst supporting the demand within the service.
• To support other members of the multidisciplinary team in planning and managing their own caseload particularly in the event of absence.
• To be responsible for prioritising and managing own workload, expecting some conflicting demands on your time.
• To support the In-Reach model into the Bedfordshire Hospitals, particularly MADE events and in times of service demand.
• To chair multi-disciplinary team caseload meetings and ensure information on individual patients is fed back to the team for planning purposes.
• To have an enhanced level of knowledge of system partners and services.
• To act as named person for the client to contact within the department and to feedback relevant issues to senior staff.
• To provide supervision and appraisals of staff within the team.
• To complete the duty rota for the Transfer of Care element of the locality team.

About us

Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive - so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.