Day to Day Duties
Identification of inpatients who are homeless. This will include people with no fixed abode, people who are at risk of homelessness, and/or people who cannot safely return to their home.
Supporting people who are homeless, or at risk of homelessness, to have a safe, planned discharge from hospital following an inpatient admission.
Liaison between Fylde Coast Housing Teams and the Blackpool Teaching Hospitals Bed Flow Team and Emergency Department. Reducing inappropriate and preventable A&E attendances at Blackpool Victoria Hospital and supporting the patient to access the services they need.
Taking referrals from Northwest Ambulance Service, NWAS, for people and who are identified with housing as a contributory factor to their health and social care needs.
Ensuring the delivery and raising the awareness of the discharge pathway for people who are homeless and ensuring the hospital Duty to Refer team, refer people who are homeless/threatened with homelessness into a Local Authority – completing these referrals when needed.
Supporting onward referrals and follow-up care including Transfer of Care and raising any safeguarding concerns.
Working across the Blackpool Multiple Disadvantage partnership to enable people to achieve a safe discharge from hospital and to access support from the right person to meet the patients needs.
Attending the weekly Multiple Disadvantage Partnership meeting and contributing to this from a homeless link worker position.
Working closely with the Care Navigators based in the homeless nursing team.
Ensure compliance to internal, local and national safeguarding procedures and advocate for patients who meet the criteria for assessment under the Care Act 2014.
Patient Identification
Use hospital systems and liaise with ward staff, discharge teams, and FCMS manager and frontline staff to identify homeless patients.
Attend wards and multidisciplinary team meetings to identify patients.
Work with Trust colleagues to support frequent A&E attenders and address underlying needs.
Help prevent unsafe or early discharges by coordinating with the hospital and community teams.
Discharge Planning & Housing Support
Complete initial needs assessments and share with local housing teams.
Notify housing teams and out-of-hours services of potential discharges.
Ensure compliance with housing legislation (Housing Act 2004, Homeless Reduction Act 2019, etc.).
Maintain discharge protocols and follow up post-discharge to confirm support is in place.
Provide patients with alternative healthcare options and refer frequent callers to appropriate services.
Maintain a Housing Options resource pack for staff and deliver training as needed.
Provide patients with details of support services available prior to discharge and undertake any relevant referrals e.g. to substance use providers.
Collaboration & Communication
Work closely with BTHFT Safeguarding adults team for all service users of the Trust.
Build strong links with inpatients, ward staff, housing teams, GP practices, Primary Care Networks and partners supporting people experiencing multiple disadvantage.
Refer patients to housing providers for accommodation and make social care referrals when needed.
Work with homeless health team and substance misuse providers to support patients at risk of self-discharge when it is believed unsafe to leave the hospital.
Attend Risk Management and Multi-Agency Oversight Group meetings.
Ensure whenever possible that no patient is discharged to the street.
Service Development
Contribute to service improvement and protocol development.
Work within organisational policies and your own competence, seeking advice when needed.
Undertake training and awareness sessions to support role delivery.
Activity Monitoring and Reporting
Complete patient contact notes in the relevant hospital system and the Homeless Health Community Instance of EMIS to provide transparency and to aid in collating reporting data.
Complete the KPI data for to include:
- Patient demographic data
- Patient locality
- No of people who are homeless or at risk of homeless and have received support with a safe discharge.
- Accommodation status
- How patients are identified
- Frequent attenders
- Number of onward referrals and who the patient has been referred to.
- No Duty to Reside data.
- Discharge outcomes including patient destination.
Quarterly Case Study: Accurately record advice and outcomes of assessment, care planning and interventions having due regard to legal aspects, confidentiality, and managerial information requirements. Provide an update report highlighting successes and challenges, for discussion at the Joint Governance meeting between FCMS (NW) Ltd and Blackpool Victoria Hospital and housing providers.
Contribute to / complete a Homeless Checklist including Duty to Refer as per the Emergency Department pathway, checklist and toolkit PowerPoint Presentation (england.nhs.uk).
Working Relationships
The main people that the postholder will be expected to communicate with will be: Patients, their carers and relatives; BTHFT Safeguarding Adults team (including ISVA & IDVA practitioners); Hospital bed flow and discharge team; Local authority housing teams in Blackpool, Fylde and Wyre Councils; Ward-based teams; Hospital emergency department; Disabled Facilities Services; Health and Social Care services; Wider multiple disadvantage support services.
Qualities required
- Self‑awareness: Living authentically.
- Adaptability – Being ready to adjust depending on the situation.
- Openness: What you see is what you get.
- Positivity with a real sense of being able to strive for the impossible.
- Generosity of spirit – Everyday should be an opportunity to act with kindness.
- Ability to have fun.
- Taking the role seriously, whilst being yourself.
Legal and Training Requirements
Disability Confident Employer: As users of the disability confident scheme, we guarantee to interview all disabled applicants who meet the minimum criteria for the vacancy.
Mandatory safeguarding training at the level applicable to this role is required.
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