Mental Health Complex Case Manager

To provide clinical advice and guidance to professionals within Integrated Discharge Service.

To support patients identified to have psychological and mild to moderate mental health needs associated with long term physical conditions.

To conduct assessments required for discharge and provide bed base care category recommendations

To triage and signpost patients to the appropriate service within their locality.

Develop robust care plans in conjunction with the patient and wider multi- disciplinary teams, to enable the patient to manage their mental health condition more confidently, which will enhance the ability to manage their long-term conditions.

Provide data that analyses the impact of mental health provision within the Integrated Discharge Service.

Undertake comprehensive mental health assessments for patients with complex mental health needs.

Utilise recognised assessment tools including 6CIT, PHQ-9, GAD-7, GDS-15, MoCA, DASS-21, MCA and Trusted Assessment documentation.

Assess emotional, psychological and cognitive needs and their impact on managing long-term conditions.

Complete risk assessments, including suicide, self-harm and safeguarding risks, escalating concerns appropriately.

Develop person-centred care plans with realistic and achievable goals.

Refer and coordinate care with secondary mental health services, GPs and other agencies where required.

Contribute to discharge planning, best interest meetings and multidisciplinary care planning.

Discharge and Case Coordination

Support patients through the Enhanced Discharge to Assess pathway.

Attend ward rounds, discharge planning meetings and multidisciplinary team meetings.

Monitor patient progress, engagement and outcomes following discharge.

Coordinate care across acute, community, social care and mental health services.

Communication and Partnership Working

Provide specialist mental health advice to healthcare professionals, patients, carers and families.

Develop effective working relationships with GPs, CMHTs, social services, voluntary organisations and acute services.

Facilitate collaborative, person-centred approaches to care across agencies.

Maintain accurate, timely and confidential clinical records.

Education, Training and Supervision

Deliver mental health education and training to healthcare professionals and partner organisations.

Provide supervision, mentoring and support to staff and students.

Participate in clinical and managerial supervision and maintain professional registration requirements.

Promote evidence-based practice and psychosocial interventions.

Service Development, Audit and Governance

Participate in service improvement, policy development and clinical governance activities.

Contribute to audits, research projects and quality improvement initiatives.

Support the development of services for older adults with mental health needs.

Monitor and evaluate outcomes including patient experience, reduced emergency department attendance and reduced length of stay.

Professional Responsibilities

Maintain compliance with NMC standards, Trust policies and mandatory training requirements.

Maintain up-to-date knowledge of mental health legislation, dementia care, safeguarding and best practice.

Working within the Integrated Discharge Service (IDS) involves supporting timely, safe and effective patient discharge from hospital through multidisciplinary and multi-agency working. The role includes early identification of discharge barriers, coordinating complex discharge plans, liaising with health, social care and mental health services, providing specialist advice to ward teams, managing safeguarding concerns, and supporting patient flow by reducing avoidable delays and length of stay.

Qualifications

Knowledge

Special requirements

Experience

Knowledge