The team to identify, assess, and co-ordinate admission avoidance /discharge for patients in the Emergency Department (ED) at the Royal London Hospital and provide follow up /rapid response in the community.
They provide specialist advice and supervision to other professions outside and within the multidisciplinary teams across organisational boundaries, and take responsibility, using a case management approach, for integrating, coordinating and pro-actively assessing patients’ health and social care needs, so that the individual receives the best possible care in the most appropriate place when they are medically stable.
They develop care plans to facilitate safe, timely and effective discharge, optimising patient outcomes and ensuring patients, carers and professionals have the skills and knowledge to implement those plans. And act as a resource for professionals of all disciplines and patients and carers, to problem solve, advise and support appropriate outcomes, contributing to and sometimes challenging the decision making process regarding whether patients are safe to be discharged from the ED to the community.
