Hospital to a Healthier Home Caseworker

PURPOSE OF THIS ROLE

The role holder is responsible for providing a dedicated service to support a safe and timely hospital discharge with proactive solutions  

This is a responsive service requiring someone who is able to juggle multiple priorities and keep them moving to enable people to get people home. 

 The purpose of the post is to work proactively with clients primarily but not exclusively older people, in both hospital and community settings, to improve their ability to live as independently as possible, for as long as possible, in their homes. This will be achieved by working within the existing local processes and pathways for health and social care, thereby identifying older people in priority need and providing individual clients with a coherent person-centered approach in which their specific needs are seamlessly considered, recognised, and responded to. The principal focus of the service is to provide bespoke home improvements and adaptations that support independence, however there are further outcome requirements related to prudent healthcare, new technology and access to services. Key to the approach is identifying with Health & Social Care partners those in critical need; ensuring effective service access to beneficiaries and tailoring interventions to the specific need.

To ensure a seamless service for clients being discharged from hospital or prevention of admission to hospital.

Key accountabilities and responsibilities

·      To be the face and direct contact of the Hospital to a Healthier Home Service. 

·      To work when required within the local Hospitals.

·      To work with the hospital teams, assisting with patients housing needs and solutions to meet those needs to enable

discharge by the planned discharge date.

·      Provide a point of contact for responding to clients or professionals calling the office in relation to urgent hospital works.

·      Visiting clients on the wards to ensure we provide advice and personalised support to the client to identify their needs and discuss personalised options to repair or adapt their home.

·      Proactively identify older frail patients with age-related challenges, complex health issues and related sensory loss, dementia or post-stroke trauma, that threaten their independence at home.

·      Promote, provide awareness and develop referral protocols for potential clients with NHS, Social Care and Third Sector teams and establish a good working relationship within the relevant local authority departments, health services, housing and voluntary groups who are in contact with the client group.

·      Work with the assessment and discharge planning processes within local clinical settings to assist in identification in a structured way, embedding a housing-related community service in the patient pathway.

·      Provide a Healthy home visit assessment that is person-centred and needs-led, identifying housing, environmental and personal risks to independent living that clients face including assessing the risk of falls, and any factors affecting the  safety, warmth and security of the property.

·      Ensure that the client understands and is kept informed of all the procedures   and practices involved with their particular circumstances.

·      Deliver targeted information, signposting and support to those individuals identified with sensory loss, dementia and stroke (and their families and friends), to ensure they are aware of the services, information, advice and support available to them to enable them to live independently.

·      Undertake brief interventions with people at high risk of losing their independence; this may include problem-solving with individual clients, supporting them to resolve issues relating to their sensory loss/dementia/stroke, living circumstance and independence, particularly at times of transition, such as hospital admission, diagnosis or discharge.

·      Use Person-Centred approaches to plan, implement, monitor and review the support you provide. 

·      Work in a fully integrated way with other members of the local health and social care teams, to ensure people receive a seamless high-quality support, in which their living circumstance are considered as an integral part of their packages of care and support.

·      Liaise with practical services/adaptations team or contractors to undertake relevant repairs and adaptations.

·      Refer to specialist support such as the Managing better Caseworker to demonstrate assistive equipment to people which would enable them to live more independently and provide information and support services for clients that want to access new technology to support independent living.

·      Have a basic knowledge of complex health and cognitive disorders, e.g. dementia, how the home environment might be improved to maximise opportunities for wellbeing and independence and how sensory loss impacts on these conditions.

·      Ensuring the service runs in line with contractual and service level agreements.

·      Provide information to the Operations Manager and other bodies monitoring the projects performance.

·      Keep up to date with developments in relevant fields of work and research.

·      Ensure that good records are kept in all cases, updating computerized     records as necessary and maintaining case notes and progress forms.

·      Contribute to the development of good casework practice throughout the agency, ensuring all casework meets the standards required by us and is in line with the Advice Quality Standard and the agency business plan.

·      Contribute to performance and monitoring reports to the standard and within  the timescales required by the agency manager.

·      To develop a creative and collaborative relationship with the Technical and Adaptations team to ensure that we can deliver on our objective of always having clients at the heart of everything we do.

·      You will be responsible for gathering and collating satisfaction surveys and providing management information on the levels of client satisfaction with the  service.

·      Ensuring that a suite of comprehensive activity-based risk management plans are up to date, relevant and communicated to the team.

·      Produce case studies which demonstrate the impact of our work.

·      To foster an excellent relationship with clients, contractors, Health and Social  Services Partners and all staff and other agencies.

GENERAL DUTIES:

·    Attend regular staff meetings and conferences.

·    Undertake other reasonable duties, commensurate with this post, as may be required.

·    To be aware of and committed to the promotion of the agency’s values, mission and diversity statements in both employment and service delivery.

·    Provide information according to the Welsh language policy.

·    Promote and maintain a customer focus.

·    Contribute to the Agency overall strategic business plan.

·    To work within the agency’s guidelines and procedures.

·    Support the smooth running of the office.

·    To adhere to Health and Safety legislation and the Agency policies and  procedures in relation to Health and Safety

IN THIS JOB YOU WILL NEED

·       Understanding of hospital pressures and experience with working hospital with discharge teams.

·       Experience of leading and promoting delivery of a project with the ability to be front facing within a hospital environment.

·       Significant experience in casework, support work, community work or a related field

·       The ability to combine your knowledge and expertise with a person-centred mindset.

·       Assessment skills, perhaps gained from professional training or experience.

·       Problem solving skills - having a flexible approach to finding solutions that  maximise independence and choice.

·       You want to work in a value led organisation and recognise yourself in the agency’s core values.

·       You have a ‘can do’ approach, remaining focused and calm under pressure. You   look for solutions which keep the processes moving because your priority is to ensure our clients receive a high-quality service.

·       Excellent listening skills in order to be able to design solutions around peoples’ wishes.

·       Skill in organizing resources and establishing priorities.

·       Time and workload management skills – being able to plan ahead and manage multiple and competing priorities.

·       Clerical, word processing, and office skills.

·       Strong interpersonal and communication skills and the ability to work effectively with a wide range of people in a diverse community.

·       Work co-operatively and enable other members of the team to work to the best of their ability.

·       Knowledge of the Welsh Government 6 goals to Urgent and Emergency Care 

·       Knowledge of the Social Services and Well-being (Wales) Act 2014 and The Well-being and Future Generations Act (Wales) 2015

DESIRABLE:

·       Up to date knowledge of welfare benefits.

·       An understanding of the needs of older people.

·       An understanding of housing issues.

·       Trusted Assessor status, or the willingness to achieve it.

·       A qualification in energy awareness (e.g. City and Guilds level 3) or experience of domestic energy advice.