Role Overview
Join a multidisciplinary team (MDT) comprising doctors, nurses, allied health professionals and community volunteers to deliver holistic social work services to End-Stage Renal Disease (ESRD) patients and their families. You will play a key role in supporting patients psychosocial well-being, facilitating access to care, and enhancing their quality of life through case management and programme development.
Key Responsibilities
1. Case Admission & Assessment
- Manage the end-to-end referral and admission process, including intake screening, financial counselling, and dialysis slot allocation
- Conduct comprehensive psychosocial assessments and develop individualised care plans for patients and their families
- Collaborate with internal MDT members and external referral partners to ensure smooth care transitions
- Provide orientation and emotional support to newly admitted patients to ease adjustment into the dialysis centre
2. Case Management
- Perform regular patient check-ins during dialysis sessions to monitor well-being and build therapeutic relationships
- Identify and proactively intervene in cases of psychosocial risks, treatment non-adherence, or financial challenges
- Conduct home or hospital visits where required to better assess patient needs and family dynamics
- Develop, implement, and review care plans for complex or high-risk cases
- Advocate for patients and connect them with appropriate community resources and social services
3. Programme Planning & Implementation
- Design and deliver patient-centric programmes and psychoeducation sessions to enhance well-being and social integration
- Coordinate programme logistics including venue setup, registration, volunteer involvement, and speaker engagement
- Monitor and evaluate programme outcomes, incorporating feedback for continuous improvement
4. Volunteer Engagement & Supervision
- Serve as the main liaison for befriender volunteers, including onboarding, training and ongoing support
- Review volunteer interaction records and follow up on cases requiring intervention
- Organise and coordinate volunteer participation in programmes, outreach and centre activities
- Provide supervision to ensure safe, effective, and meaningful volunteer engagement
- Support volunteer engagement initiatives and provide feedback to management on programme effectiveness
5. Documentation & Reporting
- Maintain accurate and timely case documentation in line with organisational and professional standards
- Prepare regular reports on programme outcomes and social service activities for management review
- Support audit processes and compliance requirements through proper documentation and participation in reviews
Requirements
- Degree in Social Work or equivalent (recognised by SASW)
- Relevant experience in medical or community social work preferred
- Strong interpersonal, communication and organisational skills
- Ability to work collaboratively in a multidisciplinary setting
