NursingNetUK

Detailed job description and main responsibilities

 ▪ To support and coordinate the transition of care for young people, aged 14-21 years with complex physical or life limiting conditions across Hertfordshire. 
▪ To enable young people with complex healthcare needs to make a smooth transition into adult care services by ensuring strategic planning of all their care needs with the support of the team lead.
▪ Develop relationships with young people and their families making comprehensive assessments of their health and social care needs. To communicate effectively at all times to ensure young people and their families are aware of pathway progression and any delays in the process.
▪ To ensure that the young person’s voice is central to decision making and that mental capacity is assumed unless assessed otherwise.
▪ Act as an advocate for young people during the transition process.
▪ Promote self-management of long-term conditions where the young person has capacity to achieve this.
▪ To ensure the dignity and respect of the patient is maintained at all times, supporting the Trust’s vision and values.
▪ To take a key worker role for young people and collaborate with professionals from both Children’s and Adult Services in health, social services, education, and other relevant agencies both locally and at tertiary centres to ensure planned referrals are made to the appropriate adult provider, in advance of discharge from relevant Children’s Service and 
to ensure unmet needs are resolved and effective transition planning takes place.
▪ To have an understanding of the provision and pathways for children’s and adult’s health, social care, education, and voluntary sector services, to enable effective provision of information and signposting to young people, parents and carers, and other relevant stakeholders throughout the transition period.
▪ To network with schools and children’s services in order to provide information for young people and families, and those who support them, on the scope and focus of adult services to manage expectations that arise in service provision during transition.
▪ To highlight training needs of the adult receiving services so that they can be addressed during the transition process. 
▪ To have an awareness of the SEND reform and EHCP process. 
▪ To support and educate young people and families in navigating health, social care, and education systems through the provision of face-to-face information and personalised support ensuring parents/carers have the information they need about a child, young person’s and family’s social care support needs and available services, in a format which they find useful and using a range of communication styles.
▪ To work as part of the multidisciplinary team, ensuring effective communication across all partners, ensuring that patient confidentiality is maintained at all times.
▪ To ensure other agencies are updated on pathway progress on a regular basis and/or when a change has occurred. To track delays and report to appropriate professional.
▪ To ensure that safeguarding children and safeguarding vulnerable adult principles are adhered to at all times throughout the transition process for all young people and are reflected in pathway and service development.
▪ To act as an appropriate and effective role model at all times.
▪ To undertake and/or assist with audits required.
▪ Organise own specialist workload, planning activities around the needs of individuals and adjusting daily diary according to priorities as they arise. 
▪ Maintain high standard of clinical records on SystmOne, ensuring all activity, both direct and indirect patient contact, is recorded accurately throughout the transition process, ensuring all supporting documents are scanned onto SystmOne on behalf of other services.