Responsibilities and Duties:
- To conduct post discharge follow-up (via phone call and/or home visit) to ensure patients and caregivers ability to cope with home care by helping to streamline and coordinate the range of community services available
- To be able to assess, analyze, recommend and implement strategies to address patient's post-discharge care needs
- To help patients and their families to plan for and improve end of life care (for patients with terminal illnesses)
- To network with other partners in ILTC setting to enhance continual support to patients and their families post discharge from community hospitals so as to ensure optimum health outcomes
- Participate in hospital activities that contribute towards improving the quality of patient care e.g. research or innovative projects that enhance patient care
- To be an advocate for patients and their families
- Main point of contact between patients, families and the healthcare team
- Develop generic care management tools to coordinate care for patients
- Identify, analyze and address key problems in the holistic management of patients
- Assist in the preparation of reports and statistics as required
Job Requirements:
- Professional qualification in Nursing, Social Work or Allied Health or/and any clinical discipline relevant to the job
- At least 3-5 years of clinical experience in nursing or related field in acute and /or community settings in Singapore
