Job Description

Job Responsibilities*
You will be responsible for the following:

• Assess and identify potential care gap or red flag that inhibits smooth transition from hospital to home and community.
• 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 and goals together with patient and/ or family/caregiver; with discussion with patient\xe2\x80\x99s care team as well as community partners involved( if any).
• Initiate conversation and discussion with patient, if required, to understand their available social care support system in order to identify potential care gap post-discharge/ post clinic consultation.
• Trigger earlier intervention and suggest suitable referral to transitional care and community support services to support patient in community and home
• 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 and follow up referrals outcome accordingly and in a timely manner.
• Adopt a multi-disciplinary approach with focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individual to address social and health issue
• Conduct 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 Physician 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.
• Maintain high level contact with step-down facilities.
• 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.
• 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 the Hospital or partners within Queenstown community.
• Any other duties as assigned by Reporting Officer.

• Degree or equivalent professional qualifications in Nursing, Social Work or Allied Health profession.
• 3 \xe2\x80\x93 5 years of experience in healthcare settings is preferred.
• Knowledge in geriatric and community care 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. Enjoys continuous improvements and embrace changes to actualize new initiatives.
• Equipped with basic computer skills in MS Words, Excel and PowerPoint.

JonDavidson