Advanced Clinical Practitioner Discharge to Assess (Pathway 2)

NHS

  • Plymouth
  • Permanent
  • Full-time
  • 9 days ago
The Discharge to Assess (D2A) Pathway 2 wasacquired by the Fuller and Forbes Partnership 18 months ago.We are looking for applicants whowill work alongside a team of GPs to deliver high-quality, patient-centered clinical care to individuals discharged from hospital into a Pathway 2 Discharge to Assess placement and who require short-term support & assessment of needs in a bedded rehabilitation setting.Main duties of the jobThe ACP will operate autonomously, managing full clinical episodes, assessing patients on registering with the service, managing periods of chronic or acute illness, diagnosing conditions, prescribing treatments, coordinating ongoing care, and supporting discharge planning. This role is crucial to ensuring timely, effective transitions of care from hospital to community and eventually to home or long-term care.About usRecently acquired by the Fuller and Forbes partnership,the DTA team is part of Mayflower Medical Group which is a collection of 5 GP Surgeries based across Plymouth. Our surgeries provide healthcare to 35,000 patients at the following locations Stirling Road, Ernesettle, Trelawny, Mannamead and Mount Gould.As a group, our vision is to enable patients to live longer and healthier lives that are full, active and meaningful. We aim to do this by developing a sustainable primary healthcare service. Our service is undertaken by our vast multidisciplinary team of GPs, Advanced Clinical Practitioners, Pharmacists, Paramedics and Nursing teams, as well as our PCN staff.DetailsDate posted26 August 2025Pay schemeOtherSalaryDepending on experienceContractPermanentWorking patternFull-timeReference numberA2381-25-0025Job locationsMayflower Medical GroupStirling RoadPlymouthPL5 1PLJob descriptionJob responsibilitiesKey Responsibilities:- Provide advanced assessment and clinical decision-making for potentially unstable patients newly transferred to D2A Pathway 2 beds.- Responsible for the assessment & treatment of both, physical and mental health needs of the individual.- Develop, initiate, and evaluate treatment plans and prescribing (if qualified).- Monitor and respond to changes in patient condition, escalating appropriately.- Collaborate with external multidisciplinary teams including physiotherapists, occupational therapists, social care teams, and discharge coordinators.- conduct clinical reviews within the D2A setting.- Support timely, safe discharge decisions and onward referrals.- Undertake comprehensive initial assessments (CGA), ensuring accurate documentation and risk stratification.- Create personalised care plans and ensure effective communication with DTA bedded providers.- Facilitate safe discharge planning in collaboration with external providers, families, reablement teams, and social services.- Act as a senior clinical leader within the D2A GP Service.- Support the development and refinement of D2A care pathways to enhance flow and patient outcomes.- Contribute to rota development and clinical cover planning.- Participate in service audits and outcome tracking.- Provide supervision, clinical mentorship and pastoral support to other team members.- Deliver informal and formal teaching on assessment and care planning in D2A settings.- Participate in audit and quality assurance projects, particularly around readmission prevention and discharge safety.- Implement evidence-based interventions to improve outcomes and reduce length of stay.Job descriptionJob responsibilitiesKey Responsibilities:- Provide advanced assessment and clinical decision-making for potentially unstable patients newly transferred to D2A Pathway 2 beds.- Responsible for the assessment & treatment of both, physical and mental health needs of the individual.- Develop, initiate, and evaluate treatment plans and prescribing (if qualified).- Monitor and respond to changes in patient condition, escalating appropriately.- Collaborate with external multidisciplinary teams including physiotherapists, occupational therapists, social care teams, and discharge coordinators.- conduct clinical reviews within the D2A setting.- Support timely, safe discharge decisions and onward referrals.- Undertake comprehensive initial assessments (CGA), ensuring accurate documentation and risk stratification.- Create personalised care plans and ensure effective communication with DTA bedded providers.- Facilitate safe discharge planning in collaboration with external providers, families, reablement teams, and social services.- Act as a senior clinical leader within the D2A GP Service.- Support the development and refinement of D2A care pathways to enhance flow and patient outcomes.- Contribute to rota development and clinical cover planning.- Participate in service audits and outcome tracking.- Provide supervision, clinical mentorship and pastoral support to other team members.- Deliver informal and formal teaching on assessment and care planning in D2A settings.- Participate in audit and quality assurance projects, particularly around readmission prevention and discharge safety.- Implement evidence-based interventions to improve outcomes and reduce length of stay.Person SpecificationQualificationsEssential
  • - Registered Nurse, Paramedic, AHP or other regulated profession, with Advanced Practice MSc or equivalent.
  • - Independent prescriber.
  • - Significant clinical experience in primary care, acute care,
  • rehabilitation, intermediate care, or complex discharge pathways.
  • - Strong autonomous assessment and diagnostic skills.
  • - Excellent communication and multidisciplinary co-ordination abilities.
  • - Skilled in using SystmOne clinical system.
Desirable
  • - Prior experience in Discharge to Assess or primary care setting.
  • - Qualification or extensive experience in frailty, geriatric assessment, chronic disease management in a primary care setting.
  • - Familiarity with CHC assessments and safeguarding procedures.
  • - Leadership experience in a primary or secondary care setting.
Person SpecificationQualificationsEssential
  • - Registered Nurse, Paramedic, AHP or other regulated profession, with Advanced Practice MSc or equivalent.
  • - Independent prescriber.
  • - Significant clinical experience in primary care, acute care,
  • rehabilitation, intermediate care, or complex discharge pathways.
  • - Strong autonomous assessment and diagnostic skills.
  • - Excellent communication and multidisciplinary co-ordination abilities.
  • - Skilled in using SystmOne clinical system.
Desirable
  • - Prior experience in Discharge to Assess or primary care setting.
  • - Qualification or extensive experience in frailty, geriatric assessment, chronic disease management in a primary care setting.
  • - Familiarity with CHC assessments and safeguarding procedures.
  • - Leadership experience in a primary or secondary care setting.

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