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Job Details

Job Title: Senior Rapid Transfer Co-Ordinator

Responsible to: Operational Lead
Locality/Directorate East Kent – Adult Clinical Services
Hours: 37.5
Last updated: March 2012
Base: Acute Sites
AFC Banding: Band 7

Description of service
The Rapid Transfer Service (RTS) is a multi-agency team, comprising staff employed by East Kent
University Hospitals Foundation Trust, Kent Community Health Foundation Trust, Kent County
Council Social Services and various voluntary organisations. There is RTS based on each hospital
site. (William Harvey Hospital (WHH), Ashford, Kent and Canterbury Hospital (K&C), Canterbury and
Queen Elizabeth Queen Mother Hospital (QEQM), Margate.

The post holder will work as a key member of the RTS, whose aim is to ensure the timely, effective,
appropriate and safe discharge of patients requiring supportive discharge, from the acute into a
community setting. The role involves liaising with hospital, community, GP’s and private facilities, in
order to promote safe and robust discharge/transfer of care.
A clinical background for this post is essential.

Based within a RTS on one of the acute sites as part of the RTS, the post holder will work at the
interface between hospital and the community, providing expert advice on discharge planning for
patients and facilitating, through holistic assessments, appropriate discharge into the community with
the support of the patients GP, Community Hospitals, Integrated Care Centres, Health and Social
Care Village Facilities, Hospice, care Homes, Community Matrons, Specialist Nurses, Intermediate
Care or Specialist Community Services. Also facilitating discharge for individuals who live outside of
East Kent.

Promote collaborative working with all other organisations and individuals to ensure effective support
for patients, according to their social and clinical needs. The post holder will actively promote and
support the principle of Home First.

To work as an autonomous practitioner as well as part of the RTS and undertaking an assessment
role to support a reduction in length of stay within the hospital, ensuring safe transfer of patients from
hospital to community settings. Supporting the wider assessment process to determine the most
appropriate discharge setting and providing the link between the hospital and community colleagues.

The post holder will assist the multi-professional team, giving support and advice, and acting as a
resource for all aspects of complex discharge planning, including NHS funded continuing healthcare.

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 1. Job Purpose
 The Post holder will work as an integrated member of the Rapid Transfer Service (RTS) to ensure
the timely, effective, appropriate and safe transfer of patients from the acute setting to the
community, liaising with hospitals, community, social and health service colleagues in order to
promote excellent discharge/transfer.

 The Post holder will hold staff members to account both internally and externally to ensure that
obstacles are removed to deliver effective and timely discharges. This will include the development
and implementation of action plans to remove such obstacles to support effective discharge.

 The Post holder will be the link member to ward staff and the emergency area and be responsible
for escalating issues that cause delay and work with the RTS Operational Lead and Clinical Nurse
Specialist to deal with these issues in a timely and effective manner.

 The Post holder will provide on-going education and development to staff across the Trust in
relation to discharge planning and the development of an innovative service, to support the
provision of excellent discharge practises within the ward environment. The post holder will support
the training and development of ward staff and other team members to ensure best practice in
planning safe and timely patient discharges, for those individuals with complex health and social
care needs, in order to achieve best outcome for patients as well as to optimise hospital bed
utilisation and reduce length of stay.

 The post holder will assist the multi – professional team giving support and advice and acting as a
resource for all aspects of complex discharge planning. This will include NHS funded continuing
health care, where they will take a lead role in facilitating the completion of the written process and
liaising with appropriate community health and social care teams.

 The Post holder will ensure that wards and clinical teams on their designated site follow and adhere
to the Trust Discharge and Choice Policy ( and all other relevant policies associated with discharge)
in order to effectively deliver safe and timely discharge and support downstream flow.

2. Dimensions

Financial and Manages The Post holder will be responsible for the
Physical verification of all reportable delays (Delayed
Transfers of Care), specific to their site, working
with all RTS and acute staff to ratify delays in
order to ensure accurate reimbursement of
funds is achieved.

Supports the delivery of safe, efficient and

effective transfer of care plans and patient
pathways, to ensure effective use of resources
and efficient patient flow.

Assists with the identification of areas for

potential improvement and works
collaboratively with patients and the MDT to
develop patient-centred transfer plans based on
assessed care needs.

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 Potential direct impact on budget expenditure
and income within the RTS
Impacts Supports the achievement of efficient and
effective patient flow throughout the acute Trust
and beyond.

Workforce Manages Motivates a wide range of multi-professional

(Bands and staff to ensure patients are assessed and
WTE) discharged in efficient and effective ways of
working are sustained.
Located All sites.
Impacts All staff and operational teams dealing with
patient flow and ways of working within the
Trust.
Other

3. Organisational Structure
Strategic Delivery Manager - Band 8C

Clinical Nurse Specialist for

Complex Care - Band 8A Urgent Care Operations
Manager – RTOC - Band 8B

Senior Rapid Transfer Clinical Resource Manager – Home Clinical Resource Manager – Out
Co-ordinator - Band 7 with Support - Band 8A of Hospital Assessment Beds –
Band 8A

Rapid Transfer HCA

Co-ordinator – Band 6 Band 4

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 5. Key Result Areas

Patient/customer care (both direct and indirect)

 The post holder will work in partnership with the multidisciplinary team to educate patients/families
to assist and enable them to make informed choices in the planning of the discharge.
 The Post holder will monitor compliance of all wards in respect to discharge planning against the
EDD and appropriately challenge ward staff and clinical teams in order to meet the assigned EDD
as appropriate, creating reports as necessary.
 The post holder will play a lead role, along with the palliative care, in the discharge planning
arrangements for patients receiving end of life care.
 Support Senior Matrons and ward managers to implement action plans to address issues identified
 The post holder will work collaboratively with IDT colleagues and ward staff to ensure effective and
timely liaison with patients, carers, and external agencies in order to initiate care packages and
other health/social care needs or equipment are in place prior to patient discharge, escalating any
delays to IDTR Team Manager or Operational Lead.
 The post holder will respond to information received on late referrals and poorly planned
discharges, liaise with relevant parties to ensure resolution and take action where appropriate to
develop and improve practice.
 The post holder will liaise with community trust and other private organisations to ensure optimum
utilisation of beds in primary care and rehabilitation, preparing patients and significant others for
impending transfer.
 The post holder will work closely with the bed mangers regarding the repatriation of patients in and
out of EKUFT.

Training and Development

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 The Post holder will take a leading role in promoting and developing the discharge planning service
across the health and social Care economy
 The post holder will assist in the facilitation of the personal and professional development of staff
across professions relating to discharge planning. The post holder will, when required deliver and
evaluate ward based training on good practice in discharge planning and current DOH initiatives.
 The post holder will take an active role in promoting and developing the discharge pathway across
the Trust.
 The post holder will teach at Corporate Trust Induction and deliver training programmes on
discharge planning at ward/ department / team level as required, including the preparation of
induction materials.
 The post holder will maintain and develop clinical knowledge relevant to the post.
 The post holder will maintain up to date knowledge for professional practice and image as outlined
in the relevant Code of Conduct
 The post holder will maintain a portfolio to demonstrate own CPD ( if appropriate)
 The post holder will participate in the In – Service Training Process.
 The post holder will ensure high standards of practice through participation in Clinical Governance
activities.
 At all times act in accordance with Trust policies, procedures and guidelines and Profession-
specific Code of Practice and Guidelines.
 The post holder will maintain confidentiality at all time.

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  The post holder will take a lead in ensuring effective team working by streamlining operational
practices across health and social care sectors.
 The post holder will contribute to the implementation of clear guidance and templates to improve
team efficiency across the health and social care sector in order to facilitate an integrated approach
to the safe and timely discharge of acute hospital patients.
 Focus on the patients individual goals by moving the complex assessment off-site in conjunction
with Social Services and improved levels of care.
 Work through the IDT in order to prevent premature admissions to long term residential care.
 Jointly within the IDT make decisions and agree actions to progress clinical pathways utilising the
experience and knowledge of the senior MDT members.
 The post holder will work proactively both internally with all health and social care organisations to
prevent complex patients’ becoming reportable delays through a solution focussed approach to
solving complex discharges.
 To support admissions avoidance and proactively manage care for frequent flyer patients’ to
prevent unnecessary readmissions.
 Support partnership working and organisational understanding to affect the optimal quality of patient
care.

Adult Research

 The post holder will support the IDT Team Manager and Operational Lead in critically analyse data
and trends causing delayed or cancelled discharges, disseminating the information to relevant
external agencies and Trust departments.

Service Development

 The post holder will demonstrate awareness of the specific discharges issues that affect smooth
transition from Hospital to Community Setting.
 The post holder will be a resource to and support staff with any internal / external process which
may hinder the discharge process, escalating as appropriate to senior personnel, issues which may
affect the smooth transition out of Hospital promoting a reduced Length of Stay in line with national
standards, adjusting practice accordingly.

Policy Development

 The post holder will contribute as required to the production of discharge facilitation policies and
procedures, keeping abreast of developments and changes regarding scheme and policies that help
facilitate safe discharge.
 To interpret health legislation and directives in relation to discharge planning and ensure thoier
effective, appropriate dissemination an implementation.

Information Management

 The post holder will utilise new and existing technology to update ward information relating to
discharge planning, inputting information into the Discharge Database as required. This will include
the updating of DTOC information and validation of delays.

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  The post holder will ensure that he reasons for the delayed transfers of care (DTOC) accurately
reflect multi-agency responsibilities which will facilitate the recording of current trends in delayed
patients.
 The post holder will oversee and support the individual wards in achieving Key Performance
Indicators in relation to Discharge planning.
 The post holder will attend relevant meetings and present information in appropriate forms to both
the Trust and external agencies on the Trusts discharge planning activities.

Autonomy

 The post holder will be expected to clinically and non- clinically challenge clinical teams and ward
staff where necessary to improve the discharge process and ensure patients’ are appropriately
discharged
 The post holder will have the autonomy to discuss clinical care with external providers (e.g district
nurse, community matron, integrated care centres, community hospitals and care homes) to ensure
that he patient is discharged to and through to the most appropriate setting for their clinical / on
clinical needs.
 This will drive the proactive discharge plan for patients from admissions and guide the clinical teams
and ward staff to facilitate specific tasks to support complex discharge.

6. Communications and Working Relationships

 Hospital Consultants
 General Practitioners
 Clinical Teams
 Hospital Matrons
 Senior Site Matrons
 Ward Managers
 Bed Managers
 General Managers
 Intermediate Care Teams
 Community Trust
 Continuing care Teams
 Community Matrons/ Specialist Nurses
 Community Nurses
 Local Referral Units
 Community Social Services Teams
 Nursing Homes
 Private Care Homes
 Voluntary Organisations

 The post holder will document all relevant information in clinical records in accordance with
Trust and local policies and guidelines relating to discharge.
 The post holder will work closely with colleagues from all key stake holders within the health
and social care economy to ensure patients’ can be discharged timely and cared for
appropriately post discharge.
 To participate in teleconferencing and chair daily caseload meetings when required.
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7. Physical Effort

 The post holder will develop strong relationships with all wards assigned to them and ensure they
are visited a minimum of once each day in order to ensure that all complex patient discharges are
being pro-actively managed to support timely discharge and improve patient flow. They will also
ensure robust plans are in place to ensure all wards are covered by the IDT, in event of annual
leave or other absence.
 The post holder will support Ward Board rounds and escalate to their line manager potential delays
or issues affecting timely discharge.
 The post holder will work daily with the Trust’s IT systems in order to prioritise workloads, monitor
performance and analyse against local and national standards and set targets.

8. Mental Effort

 The post holder will hold to account and support clinical staff in obtaining a documented discharge
care plan, discharge destination and estimated date of discharge (EDD) for all inpatients within 24
hours of admissions.
 The post holder will arrange and participate in case conferences in conjunction with Consultants for
complex discharges, promoting the safe and timely discharge of patients’. The post holder will work
to resolve patient and relatives concerns or complaints regarding discharge issues, ensuring
accountability and delays are removed.
 The post holder will advise, support and provide information to clinical staff on the management of
patients with complex discharge planning needs and act as an effective role model.
 The post holder will be able to work as an autonomous practitioner as well as with ward staff, bed
managers and associated multidisciplinary team (MDT) for the delivery of an effective expedited
discharge service.
 The post holder will provide leadership and assistance in the completion and review of paperwork
for patient case presentation.
 The post holders work pattern will at times be unpredictable with varying levels of concentration in
regard to patient related activities.

9. Emotional Effort

 The post holder will work in partnership with the multidisciplinary team to educate patinets / families
to assist and enable them to make informed choices in the planning of the discharge.
 The post holder will provide advice/information to patients , relatives and cares regarding
intermediate care, rehabilitation, nursing homes and residential care, care packages and other
services and/or sources of help available particularly in time of expedited discharges.
 The post holder will work alongside social services colleagues, providing information facilitating
respite care for relatives, whose carer becomes a hospital inpatient and ensure on-going support.
 The post holder will be frequently exposed to distressing and emotional circumstances related to the
on-going care of patients. This will involve discussing sensitive information relating to patient care
with individual patients and their families in order to agree the most appropriate level of care for
respective patients.

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  At times, difficult decisions will need to be made and the post holder will have to provide the
necessary information to all parties in order to make an informed decision about a patient’s on-going
level of care.

10. Working Conditions

 Frequently exposed to unpleasant and /or occasionally/ frequent highly unpleasant conditions on
ward through daily exposure to smells, noise, dust, bodily fluid from patients on wards through
working up their individual discharge plans.

11. Most Challenging Part of the Job

 Ensuring that all staff involved in clinical care and management of the patient journey are fully
equipped with the knowledge and skills to deliver the smooth transition from acute care to non-
acute care as part of the discharge process.
 To continually challenge teams and wards on the processes required to ensure that patients are
discharged in a safe and timely manner.

We confirm that the details of the post as presented are correct. This is a description of the duties of the
post as it is at present. This is not intended to be exhaustive. The job will be reviewed on a regular
basis in order to ensure that he duties meet the requirements of the service and to make any necessary
changes.

This should be read in conjunction with the Trust Job Description Clauses document.

Job description agreement

Job holder’s name

Job holder’s signature:
Date:
Line managers name and
title
Line managers signature

Date

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Person Specification

POST: SENIOR Rapid Transfer Co-Ordinator

ESSENTIAL DESIRABLE Measurement
Nursing degree Community Application Form
EXPERIENCE & Occupational Therapy degree experience or
QUALIFICATIONS Physiotherapy degree qualification.

1st Level Registered nurse Experience of

NMC registration working within
both acute and
OR primary care.

At least 5 years NHS

experience with two years Application Form
working at Band 6 level within
discharge planning/ Health
&/or Social Care environment
or similar

And Application Form

Application Form
Masters degree of evidence of
working at Master’s degree Application Form
level through equivalent
experience

Evidence of line management, Application Form

leading and managing teams

Practical experience in
managing health related
projects/complex caseloads

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 Evidence of recent study and
continuing professional
development.

SKILLS & Excellent and effective Demonstrate and Application Form

ABILITIES communication skills, written understanding of Interview
and oral. issues related to Questioning
equal References
opportunities
Ability to converse in a
positive manner with all levels Experienced and Application Form
of staff, patients and proficient in word Interview
relatives/carers. processing, Questioning
database and References
spreadsheet

Resourceful, ability to work on Teaching and Application Form

own initiative and apply presentation skills Interview
judgement. Questioning
References
Ability to remain calm under
pressure, and in stressful Application Form
situations. Interview
Questioning
Ability to work efficiently on a Reference
multidisciplinary basis both
internal and external to the Application Form
organisation Interview
Questioning
Demonstrate understanding of References
issues related to
confidentiality of data and
patient information. Application Form
Interview
Ability to act as the patient’s Questioning
advocate. References

Able to demonstrate a patient Application Form

orientated approach to work. Interview
Questioning
Experience of resolving References
complex transfers
Application Form
Ability to demonstrate Interview
personal resilience, especially Questioning
under times of pressure References

Ability to manage time effectively, Application Form

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 priorities and work under Interview
pressure to meet deadlines Questioning
References
Ability to work effectively with a
variety of people at all
organisational levels across
different sectors including areas
Application Form
of social deprivation Interview
Questioning
References

Application Form
Interview
Questioning
References

KNOWLEDGE A good understanding of the NHS plan. Application Form

importance of discharge
planning and the discharge Clinical Interview
process and a good Governance.
knowledge base of welfare Questioning
and benefits rights, overseas NMC Agenda.
patients, homeless patients References
Essence of Care
Knowledge of National Polices
and Acts relating to legislation Experience of
to support safe and implementing
sustainable discharge. audits
Kno Experience of
utilising
Proven ability to develop research/evidence
effective partnerships to based practice
achieve practical outcomes
across organisational Evidence of
boundaries including statutory innovation in
organisations, external previous roles
agencies, community and
voluntary organisations

Supporting others (mentor /

educator / supervisor )
experience

PERSONAL Excellent interpersonal skills Interview

QUALITIES Questioning
Dynamic, flexible personality References
capable of inspiring confidence
Interview
Have good negotiating and
Questioning
facilitating skills
References
Highly motivated

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 Demonstrates leadership Interview
qualities Questioning
References
Reliable, conscientious and
flexible in approach to work to
meet the needs of the service

Committed to self and staff

development

ABILITY TO Able to support the

MANAGE implementation of local and
national agenda’s for health
under the guidance of the senior
Practitioner

Ability to prioritise care delivery in

a professional manner, taking
into account Trust policies and
procedures.

Ability to manage own time

effectively.

OTHER To be aware of and adhere to the Application Form

Trust’s Vision, Mission and Interview
Values Questioning
References

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