Case Management Officer

Job Descriptions

1. Work with the identified patient (spanning across adolescent, adult to elderly age groups) to plan and coordinate his/her care, activities and discharge based on his/her clinical, physical, psychosocial, cultural and other identified needs.
2. Function as a resource person in the assessment of complex patient care needs / situations and plan for interventions.
3. Monitor discharge care plans, and evaluate the effectiveness of care at the next level in continuum
4. Collaborate proactively with hospital's multi-disciplinary team members, provide coordination and continuity of patient care across the healthcare continuum with primary care and community mental health partners to facilitate smooth transition of patient to the home and into the community.
5. Cooperate with the community mental health partners to follow up with care plan if necessary, when there is variance from the discharge care plan.
6. Assist to plan, coordinate and conduct mental health related educational activities for NUHS staff, primary care partners, community mental health partners and the public.
7. Conduct house visits to patient and interact with patient's caregiver/family members when needed.
8. Monitor and maintain programme database and indicators