Job Description

JOB SUMMARY
The Right Siting Coordinator, Care Transition Services will support acute hospitals to right-site discharged patients (from inpatient, outpatient, and Emergency Department) appropriately and efficiently into primary and/or community care. The settings are not limited to GPs/ Family Medicine Centres /Polyclinics and community care programmes. Senior/ Care Coordinator will support the process of identifying patients suitable for right-siting together with clinicians and clinic managers, enrolling eligible patients with a primary care doctor, providing relevant information to patients, and facilitating the care transfer to the community and vice versa if necessary. This includes working with GPs/FMCs/Polyclinics, SOCs, Emergency Department, Community Health Team, PHC Primary Care Office (PCO), MOH and agencies on collation of regular reports of various patient administrative indicators as required by MOH and management. In addition, Coordinator will also upkeep repositories of community resources and provide the bridge for access to resources available at primary and community care.
SPECIFIC (80%)

• Liaise with Clinicians, Nurses or Operations with regards to patients who are identified for right siting to primary care and community care.
• Prepare all relevant documents required during counseling of patients or/and their family.
• Counsel and assist patient with discharge and/or enrolment (e.g., Healthier SG) to a primary care doctor.
• Facilitate patients' care at primary care/ community care upon discharge from hospital.
• Maintain and update patients' database for monitoring and reporting.
• Provide monthly statistics to Supervisors and submit KPIs and clinical indicators as and when required.
• Facilitate care discharge discussions with patients/caregivers and assist with the care siting process (e.g., to primary care and community care partners)
• Monitor, update and highlight these queries or feedback regularly so that revisions of work processes may be continuously performed.
• For returned visits to the hospital, triage urgency with Clinician and schedule outpatient review as instructed.
• If needed, arrange pre-appointment screening tests at referral source to minimise patients' hospital visits and ensure results are available prior to outpatient appointment.
• Coordinate and maintain a database on patients so as to track their progression into the various stages of the program for audit and registry.
• Demonstrate knowledge and the ability to monitor and coordinate care processes for patients.
• Provide periodic right siting updates and new workplans to Clinicians, Nurses and Operations.
• Collaborate closely with Clinicians, Nurses and Operations to establish structured right-siting workflow and processes for SOC, Inpatient and ED, when new disciplines come onboard. Perform regular reviews and patient data clarifications for various programme reporting, such as drug subsidy report and leak back report.
• Maintain and update discharge planning repositories (e.g., list of service providers, referral flow details etc.) and proactively communicate updates and required information to patients/caregivers and colleagues involved in the discharge processes.

GENERAL (20%)

• Communicate with referring physicians, other health care providers, Primary Care Partners Office and other organisations regarding the patients' status and outcome.
• Support in training new care coordinators on daily activities and patient care within the programme.
• Collect, ensure accuracy of registry data for planning team's review.
• Assist to coordinate monthly team and department meetings to raise agenda for discussion

OTHER DUTIES AND RESPONSIBILITIES

• Identify areas for improvement and participate in quality improvement initiatives
• Attend training courses as deemed necessary for work assigned.
• Prepare to undertake any suitable task as assigned by the Supervisor.

ORGANISATION RELATIONSHIPS
SUPERVISOR'S SUPERIOR : Director / Deputy Director/ Assistant Director/ Senior Manager/ Manager, CTS
SUPERVISOR : Senior Manager/ Manager/ Assistant Manager/ Senior Executive, CTS
SUBORDINATE : Nil

Skills Required