Job overview

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.

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•        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.

Working for our organisation

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

Detailed job description and main responsibilities

PLEASE NOTE: Please see attached Job Description and Person Specification.   To apply, please click APPLY FOR THIS JOB - this link will take you to the TRAC Recruitment Site.  You will need to register if you do not already have an account.

Derbyshire Community Health Services NHS Foundation Trust (DCHS) is one of the largest providers of specialist community healthcare in England and we currently employ around 4,500 staff.  We deliver a variety of services across Derbyshire, caring for nearly 1.8 million patients each year.

We deliver patient care through 11 community hospitals, 4 minor injury units, 29 health centres and a learning disability centre.  Another key part of our service is out in the community where we care for people in their own homes via therapists, health visitors and district nurses, and promoting public health in the wider community.  As a Trust we care for patients of all ages with a special focus on the needs of elderly people and the very young.

DCHS has been recognised as a top 10 NHS organisation to work for in the UK by the Health Service Journal and NHS Employers in their Best Places to Work 2015 campaign.  The Trust is also the runner-up in the category for the best NHS community trust employer.

TWITTER/FACEBOOK - DCHS has its own Social Media accounts for recruitment. Follow us/like us via @dchsjobs

Our vision “to be the best provider of local healthcare and to be a great place to work”

Our values:

1) To get the basics right
2) To act with compassion and respect
3) To make a difference
4) To value and develop teamwork
5) To value everyone’s contribution because everyone matters

The majority of our locations offer free parking facilities for staff.

We will communicate with you regarding your application via email so please check your email account on a regular basis.  If using hotmail, MSN or yahoo email accounts please check your 'junk/spam' mail regularly.

If you require any support in completing the application form please do not hesitate to contact the Recruitment Team,   01332 564856, option 1, option 1  or   [email protected]  and we will be happy to provide assistance.

Please note - if we receive a high number of applications for this position we reserve the right to withdraw the post before the closing date, therefore it is advisable that you apply as early as possible to avoid disappointment. 

As a flexible working friendly organisation, we want to be sure that you can work in a way that is best for our service and for you.  Speak to us about how we might be able to accommodate a flexible working arrangement whether that's job share, part time or another flexible pattern.