Role Summary:
Home from Hospital Co-ordinators will develop strong relationships with local hospital teams and the 5 discharge hubs to identify appropriate referrals.

They will take referrals to the service and carry out dynamic risk assessments to prioritise support and provide clients with short-term practical and emotional support at home to reduce the risk of re-admission to hospital and assist in their return to independence.

Referrals and Assessment:

• Take referrals via single point of access phone line, dedicated email or web forms.

• Carry out initial dynamic risk assessment to prioritise and grade support needed.

• Allocate referrals in priority order to team members in relevant locality.

• Liaise with the locality Discharge Hub (one of 5 discharge hubs across North Yorkshire) to identify and receive appropriate referrals as per the Discharge to Assess model.

• Carry out pre-discharge planning work as appropriate

Service Promotion:

• Builds positive relationships with hospital teams to promote the service, attending relevant meetings and ward rounds as required to generate referrals.

• Promotes the service to relevant health and community services – e.g. NYCC discharge hubs, Re-ablement, Living Well, community response teams, GP practices etc.

Provide client support:

• Following allocation of referral, establishes contact to assess client needs, assisting them to set individual goals and developing a support plan with the client.

• Provides practical help and support at home, which is not already available, to meet the individual’s identified needs.

• Actively refer and/or signpost clients on to appropriate service providers to meet their immediate and ongoing needs.

• Recruit, manage and retain volunteers to support clients.

• Liaises with Health and Social Care professional and family as appropriate.

• Identify Carers and cross refer these to Carer support services as appropriate.

General:

• Efficiently manages a caseload of clients, ensuring effective liaison with other agencies.

• Ensures all processes and procedures are adhered to in the safe delivery of the service, keeping up to date confidential accurate records (electronic and/or paper).

• Assists the Programme Manager with monitoring and evaluation of the service and its clients, ensuring progress and success of the scheme can be continually demonstrated.

• Supports and supervises volunteers as appropriate and participates/assists in facilitating volunteer training where required.

Working with others:

• Demonstrates effective team working skills, interacting well with other departments and participates in team meetings and training.

• Displays self confidence and initiative.
• Makes a positive contribution to Carers’ Resource, is willing to function as a member of a small team and proactively assist in the development of the organisation.

• Demonstrates active listening and observational skills, accepting and learning from feedback.

Understanding the organisation:

• Assists with the analysis of trends and recommendations for service improvement.

• Acts as ambassador for Carers’ Resource, protecting and promoting its good name and reputation at all times, and contributing to its development.

• Works within policies and practices of Carers’ Resource, follows health and safety procedures and maintains confidentiality.

• If required, participates as a representative of Carers’ Resource, in multi-agency meetings, voluntary fora and other events, feeding back appropriately to line manager and the team.

Developing personally:

• Takes responsibility, in consultation with line manager, for personal development and progression, participating in performance reviews and undertakes any training deemed necessary.

• Keeps up-to-date about services, benefits and organisations available to clients.

• Good timekeeper and good attendance.