The Reablement Care Coordinator serves as the central coordinator of the client's reablement journey, ensuring seamless integration across disciplines, programme phases and community resources. The role bridges healthcare, social care and community support systems to facilitate meaningful and sustainable outcomes for seniors.
Key Responsibilities:
Care Coordination and Case Management
- Lead end-to-end coordination of the 12-week reablement pathway.
- Conduct intake triage, screening and enrolment of programme participants.
- Review Clinical Frailty Scale (CFS) levels and population health datasets to support participant selection.
- Consolidate interdisciplinary assessments into a unified reablement plan.
- Coordinate intervention schedules across multiple disciplines and stakeholders.
Outcome Monitoring and Programme Evaluation
- Monitor client progress using validated outcome measures including INTERAI, COPM and ASCOT.
- Identify barriers to progress and coordinate intervention modifications.
- Maintain accurate programme documentation and outcome records.
Multidisciplinary Team Coordination
- Facilitate case conferences and interdisciplinary reviews.
- Coordinate communication among therapists, nurses, social workers, therapy assistants and community partners.
- Ensure continuity of care throughout programme phases.
Community Reintegration and Sustainability
- Coordinate transition plans into Active Ageing Centre programmes, CARE Market initiatives, SEED programmes, volunteer opportunities and microjob pathways.
- Support development of sustainable participation plans beyond programme discharge.
Long-Term Follow-Up
- Conduct 6-month and 12-month follow-up reviews.
- Monitor for early signs of decline and facilitate timely reactivation of services where required.
Qualifications:
- Degree in Nursing, Social Work, Occupational Therapy, Physiotherapy or other relevant healthcare discipline.
- Minimum 2 years of experience in healthcare, community care or case management settings.
- Strong stakeholder management and communication skills.
- Experience coordinating care across multiple service providers.
- Proficiency in Microsoft Office applications
- Experience in community care, transitional care or active ageing programmes.
- Familiarity with INTERAI, COPM, ASCOT or equivalent outcome measures.
- Experience in programme development and service improvement initiatives.
- Training in Motivational Interviewing or health coaching.
- Comfortable conducting home visits and community-based interventions
