Senior Care Coordinator (Contract, Part Time)

Overview

Identification and triage of unmet social, behavioural, and care coordination needs Social prescribing and referral to appropriate services e.g. Advance Care Planning Reinforcement of available support channels e.g. Virtual Care Centre. To deliver this function at scale and with fidelity, the incumbent will assess social determinants of health of patients, initiate and track social prescribing referrals, coordinate enrolment into relevant community and hospital programmes, and ensure structured documentation and follow-up.

He/She enables systematic risk identification, timely intervention, and coordinated care navigation for approximately 1,000 high-risk discharge patients over the grant period.

• Integration of patient care during the transition phase
• Familiarize with goals of discharge for patient in list..
• Perform phone call check in with patient to ensure patient is familiar with the discharge plan.
• Ensure hospital processes are well coordinated for the patient.
• Community support and integration
• Identify social risk profile of patient (independent / need help)
• Perform social phone check in on a periodic basis (3/6 mths) on patient to establish relationship and to ensure patient is able to stay well in the community
• Ensure patient know how to get help in the event of medical emergency.
• Patient enrolment and care coordination
• Check if patient is on board target programmes such as HSG, ACP, AAC
• Introduce such programmes to the patient and take consent for patients to be contacted to enroll in the programme
• Share about the benefits of such national programmes
• Patient Education
• Provide patient education (e.g. basic health education on lifestyle modification, care plans.and refer to appropriate interventions if not done.
• Patient care coordination
• Make appropriate referrals for follow-up according to patients’ health and social needs.
• Coordinate the care for patients with other providers and facilitate seamless transitions.
• Outcome tracking
• Administer QoL / outcome questionnaire to check quality of intervention
• Appropriate documentation and communication
• Perform accurate documentation in the delivery of patient care and the coordination process.
• Communication abilities
• To effectively work in collaboration with key stakeholders in the evaluation and quality improvement processes.

• Must have Degree in Nursing
• Strong communication skills both written and spoken
• Possession in community service knowledge, the concept of case management and experience in care coordination or service linkage for the patient is preferred.
• Good working knowledge of MS Office.
• Experience in nursing / case management / care coordination / social work/ service is preferred.
• Is passionate working with the older people and keeping them healthy in the community.
• Has experience in engaging community partners.
• Suitable for former nurses with a wealth of life experience