Medical Social Worker

The role works collaboratively with the multidisciplinary team to enhance residents' quality of life, support informed decision-making, and ensure smooth transitions across care settings.

1. Intake, Assessment and Admission Support

• Partner with Nursing staff to conduct intake screening for prospective residents/clients.
• Perform comprehensive psychosocial assessments to understand residents' and families' social, emotional, financial, caregiving, and support needs.
• Identify residents and families requiring ongoing psychosocial, emotional, spiritual, or practical support.
• Participate in pre-admission and admission assessments as required.
• Support newly admitted residents and families in their adjustment and transition into the care environment.
• Conduct InterRAI assessments and related evaluations to support resident care planning and clinical documentation requirements.
• Ensure timely and accurate documentation of assessments, interventions, and care plans in the designated systems.

1. Casework, Counselling and Care Management

• Provide counselling, emotional support, and psychosocial interventions to residents and their families.
• Conduct case management and coordinate referrals to appropriate community resources, social services, healthcare providers, and government agencies.
• Provide information, referral, and guidance on available government schemes, financial assistance, and community support services.
• Follow up with families experiencing financial difficulties and facilitate access to relevant assistance programmes where appropriate.
• Manage and monitor assigned caseloads to ensure timely intervention and continuity of care.
• Maintain accurate, timely, and confidential case documentation in accordance with organizational policies and PDPA requirements.

1. Advance Care Planning (ACP) and Quality Care Discussions

• Facilitate Advance Care Planning (ACP) discussions with residents and families to support informed healthcare decision-making and future care planning.
• Conduct and document ACP conversations, ensuring residents' values, goals, and care preferences are accurately captured.
• Conduct facilitation sessions monthly or as required.
• Promote ACP awareness among residents, families, staff, and community stakeholders.
• Support the business expansion of ACP services to external outpatient and community partners through stakeholder engagement and collaboration.
• Ensure long-term residents have completed ACP, Preferred Plan of Care, or other relevant care planning documentation where appropriate.
• Provide guidance and referrals regarding Lasting Power of Attorney (LPA) and related matters when required.

1. Discharge Planning and Care Transition

• Collaborate with medical, nursing, rehabilitation, and allied health professionals to develop and implement discharge and transition plans.
• Work with residents and families to identify appropriate post-discharge care arrangements.
• Facilitate right-siting of residents to suitable care settings based on changing care needs.
• Coordinate referrals and admissions to nursing homes, community hospitals, hospices, home care services, and other relevant agencies.
• Liaise with receiving agencies and service providers to ensure smooth transitions and continuity of care.
• Support discharge planning for respite care residents and coordinate long-term placement arrangements where required.

1. Respite Care Coordination

• Receive and assess planned and urgent respite care referrals.
• Coordinate admissions, assessments, and care planning for respite residents.
• Work closely with families, community partners, and care teams to develop appropriate long-term care solutions.
• Facilitate placement planning, discharge arrangements, and transition to permanent care settings when necessary.

1. Crisis Intervention and Family Support

• Conduct risk assessments and interventions for residents and families experiencing crisis situations, including:
• Suicide risk assessment
• Family violence concerns
• Caregiver distress and burnout
• Grief and emotional crises
• Develop and implement intervention plans in collaboration with the multidisciplinary team.
• Provide family education, mediation, and conflict resolution support.
• Support staff and team members in managing emotional challenges arising from resident care situations.

1. Palliative Care and Bereavement Support

• Facilitate End-of-Life (EOL) discussions with residents and families.
• Explore and document residents' preferences, wishes, values, and goals relating to end-of-life care, including:
• Last rites and cultural practices
• Personal wishes, hopes, and regrets
• Life review and legacy work
• Closure conversations and family reconciliation
• Provide information and referrals relating to wills, nominations, and advance care planning matters.
• Coordinate funeral arrangements for residents without next-of-kin or where support is required.
• Provide bereavement support and follow-up to families following a resident's death.
• Conduct bereavement check-ins and short-term counselling, and facilitate referrals for longer-term support where necessary.

1. Resident Engagement and Partnership with Hospitality team

• Facilitate therapeutic group work, support groups, and psychosocial programmes for residents.
• Organize and facilitate household committee meetings and resident feedback sessions.
• Partner with the Hospitality Team to plan and support resident engagement activities, outings, celebrations, and special events.
• Contribute to the planning of festive celebrations, birthdays, community events, and meaningful social programmes that enhance residents' quality of life.
• Promote resident participation, inclusion, and social connectedness within the care environment.

1. Multidisciplinary Collaboration

• Participate actively in multidisciplinary team meetings, case conferences, and care planning discussions.
• Advocate for residents' psychosocial needs and contribute professional recommendations to support holistic care planning.
• Collaborate with internal and external stakeholders to achieve optimal resident outcomes.
• Build and maintain effective partnerships with healthcare institutions, community agencies, and service providers.

1. Administration, Quality and Professional Development

• Ensure compliance with organizational policies, professional standards, regulatory requirements, and ethical guidelines.
• Maintain accurate records, reports, statistics, and documentation.
• Keep abreast of developments in healthcare, social services, government policies, funding schemes, and community resources.
• Support service development, quality improvement initiatives, and programme evaluation activities.
• Participate in professional development and continuous learning activities.
• Assist with departmental projects and organizational initiatives as assigned.

1. Other Duties

• Attend to public enquiries, walk-in consultations, and service referrals.
• Perform any other duties and responsibilities assigned by the Reporting Officer or Management that are consistent with the scope of the role.

1. BA (Major in Social Work) or Bachelor Degree in Social Work OR Graduate Diploma in Social Work.
2. Experience working with Older Adults and People with Dementia
3. 3 – 5 years’ relevant experience preferably in hospital or community hospital setting.
4. Microsoft office, internet savvy
5. Accreditation with Social Work Accreditation and Advisory Board (SWAAB) - Registered Social Worker
6. Certification for Advanced Care Plan Facilitator (preferably)
7. Possess good communication skills and knowledge