Job Description

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\xe2\x80\x99s 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\xe2\x80\x99s lifestyle in the community.
Monitor patient\xe2\x80\x99s general medical condition during home visit and report to patient\xe2\x80\x99s 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\xe2\x80\x99s 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.

EnviroDynamics Solutions