Band 4 Assistant Practitioner
Integrated Transfer of Care (ITOC) Team
Hours per Week: 37.5 Hours Per Week across 7 days 08:00-20:00
Job Type: Permanent

The Integrated Transfer of Care (ITOC) Team is a dynamic and multi-skilled team consisting of nurses, occupational therapists, physiotherapists, and Assistant Practitioners. We also work in alignment with social services and private sector nursing and residential homes.
Our purpose is to support a safe and timely hospital discharge of people who are medically fit, and no longer need hospital care, to a place more suitable to the person’s needs. Assessments and care provision can then be tailored to support people to regain strengths and skills so that they can live as independently as possible. We also aim to avoid admission for patients in A&E and Frailty departments who require intervention to allow them to be discharged home.

The main priority of the team is to consider home first with ongoing community interventions, if required

The ITOC model aims to support better outcomes for people leaving hospital by:

• Reducing the time people spend in hospital when they no longer need acute care preventing hospital acquired infections and ‘deconditioning’ (the loss of strength and independence)
• Assessing people in a more appropriate environment than the hospital giving a more accurate indication of their strengths and needs
• Providing multidisciplinary reablement and rehabilitation plans, and if necessary short-term care and support, to help people gain and re-gain independence, preventing or reducing need for longer term care.
• The model also enables the urgent care system to prioritise acute hospital care for those people who need it.

The ITOC teamwork in partnership with individuals and families to identify their own needs and short term goals, recognising that person-centred care planning and intervention is key to the person accomplishing the outcomes they want to achieve.

They also closely work with other services as part of the ‘Urgent Care System’. Key Stakeholders, Urgent Care Response, HATs, and Social Services. There are two teams within the service: The Hospital Discharge Team identify people who have onward care needs and then make necessary arrangements for discharge to one of the two pathways within the D2A service; Home First and Bedded Pathway.

Home First is the default pathway for people leaving hospital and should be the first consideration for everyone. The team will work with the individual and determine if support is required to return home and arrange the necessary support for discharge

Where people are unable to go home immediately, they will be discharged to the Bedded Pathway. This means they will be placed in a residential or nursing care home where they will be assessed by a member of the D2A multidisciplinary team. The D2A team will work with the person to identify the type of care, support or rehabilitation they need to meet the outcomes they want to achieve including, wherever possible, a return home.

Longer term needs will be assessed following a period of intermediate care.
Both sides of the team come together to cover A&E and Frailty patients across Kirklees.
Locala is committed to helping employees achieve a positive work- life balance and promotes mobile working. Staff are provided with mobile technology.

There will also be opportunities to broaden your scope of practice through supporting across the wider service of Unplanned and Intermediate Care