Community Clinical Sister- Integrated Front Door Nurses

Use skills and knowledge to assess the physical and psycho social needs of the patients in their own homes within 24 hours of hospital discharge Including observations, medication checks, and skin checks. To work with the hospital Discharge Team to facilitate safe, timely and appropriate transfers from wards for patients who are known to place based teams Anticipate short and long term care needs and develop appropriate care plans for patients in order to prevent unnecessary readmissions to hospital including emergency passports.