Job Description

Overview

The Care Coordinator supports and works within Alexandra Hospital, and collaborates with community service providers, government agencies, and multi-disciplinary hospital and healthcare teams to provide coordination and continuity of patient care across the healthcare continuum; to support patients and their family members in navigating their healthcare journey with Alexandra Hospital within the Queenstown community.

Job Responsibilities

You will be responsible for the following:

Recruit high risk patients whom benefit from transitional care and case management support through Multiple Disciplinary Meetings, referrals, screenings

Triage and assess patient's medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.

Synthesize assessment information to prioritize care needs and develop care plan goals together with patient, family/caregiver and the community care team.

Implement appropriate care coordination and transitional case management; and evaluate the outcomes accordingly.

Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient's community. Coordinate the necessary referrals accordingly and in a timely manner.

Provide a valuable link by ongoing collaboration among the patients, families/caregivers and the multidisciplinary teams on a timely basis.

Conducts follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.

Promote and guide positive changes in patient's lifestyle in the community.

Monitor patient's general medical condition during home visit and report to patient's Principal Doctor or primary care provider and/or community partner where necessary.

Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.

Document assessments, plans, and outcomes promptly and accurately in the relevant system.

Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient's best interests.

Assist and guide team to attend to queries receive via an integrated telephone hotline that forms a network for triaging patients, and provides an avenue to caregivers and community partners to connect with Alexandra Hospital for information relating to the health and well-being of patients and clients within Queenstown community espcially after patient's discharge.

Station in community healthcare posts when needed, where patient/ residents can be cared for conveniently within their community.

Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.

Participate in projects and/or community events organized by Alexandra Hospital or partners within Queenstown community.

Any other duties as assigned by Reporting Officer.

Requirements

Degree or equivalent professional qualifications in Nursing, Social Work, Counselling and Psychology with at least 3 years' experience are preferred.

Those with Diploma for the above professional tracks and has at least 5 years of experience in related field in acute and/or community setting in Singapore will be considered.

Knowledge in geriatric care, chronic diseases management, and experience in home healthcare and home personal care and other community services will be an advantage.

Strong team-player, with natural ability to interact with healthcare staff and community partners of all levels.

Organised, analytical, able to fit different pieces of the puzzle together.

Pleasant disposition, approachable, with strong interpersonal and relational skills.

Good verbal and written communication skills. Ability to use local languages and dialects will be an advantage, especially coupled with experience interacting with and managing patients and caregivers.

Independent worker, with strong initiative.

Comfortable with ambiguity, unchartered territory, enjoy challenges and problem solving.

Equipped with basic computer skills in MS Words, Excel and PowerPoint.

Experience and ability to work shifts may be an advantage for specific roles within the team.