Home from Hospital Coordinator

Accept referrals for routine support for people being discharged from hospital triaged
through the Home from Hospital team.
● Oversee the email account and ensure referrals are picked up daily and
actioned.[HC1]
● Undertake holistic client assessments using the P-CAT tool to ascertain the needs and
outcomes of people referred to the service and review at regular intervals.
● Work with service users to co-produce a personalised support plan based on the
person's priorities, interests, values and motivations -"What matters to me".
● Monitor, coordinate and review service users' support plans including regular welfare
checks, casework and onward referrals.
● Coordinate and supervise the work of RR SWs and face-to-face befrienders.
● Match service users receiving 4-week support with RR SWs and face-to-face befrienders.
● Work with external agencies on behalf of service users.
● Refer and/or signpost service users to other Age UK Sutton services and Sutton's wider
provider network.
● Effectively communicate accurate and impartial information and advice to older people
with a wide range of support and communication needs.
● Effectively manage case work and service user relationships to ensure excellent service
user care and accurate recording of actions and outcomes.
● Keep up to date with relevant changes in legislation, policy and procedures, both locally
and nationally and as they apply to and affect older people and their carers.
● Work closely with the Volunteer Team to facilitate the smooth and timely referral of
service users to the 8-month HfH Community Connector Befriending service.
● Assist service users develop their confidence and independence through shared goal
setting and effective person-centred working practices.
● Work in a variety of settings including the hospital, community settings, and clients'
homes.
● Develop effective working relationships with hospital MDT (multiple disciplinary
teams), Sutton Health & Care teams, START team, Community Health/Therapy teams
GPs and SPS to facilitate the smooth step downs and step ups of patients/older
people on the discharge pathway.
Volunteer Management
● Recruitment, support and supervision of volunteers delivering the 4-week programme
ensuring they provide a quality service and have a good experience of volunteering within Sutton, in particular to support clients at risk of loneliness and isolation.
Risk Assessment and Safeguarding
● Complete risk assessment of service users' homes to ensure RR SWs and volunteers are
working in a safe and healthy environment and service users are as safe as reasonably
possible within their homes.
Service Marketing, Engagement and Promotion
● Promote the service making effective use of local media, email.

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To speak to a recruitment expert please contact Joan Collins