Care Manager, Community Care Coordination Unit(5758)

2 weeks ago

Singapore National University Health System Pte. Ltd. Full time
Overview*

The Care Manager supports and works within Alexandra Hospital, and collaborates with patient's care team, community service providers, government agencies, and multi-disciplinary hospital and healthcare teams to provide coordination and continuity of patient care across the healthcare continuum; to support patients and their family members in navigating their healthcare journey with Alexandra Hospital within the Queenstown community.

Job Responsibilities*

You will be responsible for the following:
  • Assess and identify potential care gap or red flag that inhibits smooth transition from hospital to home and community.
  • Triage and assess patient's medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
  • Synthesize assessment information to prioritize care needs and develop care plan and goals together with patient and/ or family/caregiver; with discussion with patient's care team as well as community partners involved( if any).
  • Initiate conversation and discussion with patient, if required, to understand their available social care support system in order to identify potential care gap post-discharge/ post clinic consultation.
  • Trigger earlier intervention and suggest suitable referral to transitional care and community support services to support patient in community and home
  • Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient's community. Coordinate and follow up referrals outcome accordingly and in a timely manner.
  • Adopt a multi-disciplinary approach with focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individual to address social and health issue
  • Conduct follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.
  • Promote and guide positive changes in patient's lifestyle in the community.
  • Monitor patient's general medical condition during home visit and report to patient's Principal Physician or primary care provider and/or community partner where necessary.
  • Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.
  • Document assessments, plans, and outcomes promptly and accurately in the relevant system.
  • Maintain high level contact with step-down facilities.
  • Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient's best interests.
  • Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.
  • Participate in projects and/or community events organized by Alexandra Hospital or partners within Queenstown community.
  • Any other duties as assigned by Reporting Officer.
Requirements*
  • Degree or equivalent professional qualifications in Nursing, Social Work or Allied Health profession.
  • 3 - 5 years of experience in healthcare settings is preferred.
  • Knowledge in geriatric and community care will be an advantage.
  • Strong team-player, with natural ability to interact with healthcare staff and community partners of all levels.
  • Organised, analytical, able to fit different pieces of the puzzle together.
  • Pleasant disposition, approachable, with strong interpersonal and relational skills.
  • Good verbal and written communication skills. Ability to use local languages and dialects will be an advantage, especially coupled with experience interacting with and managing patients and caregivers.
  • Independent worker, with strong initiative.
  • Comfortable with ambiguity, unchartered territory, enjoy challenges and problem solving. Enjoys continuous improvements and embrace changes to actualize new initiatives.
  • Equipped with basic computer skills in MS Words, Excel and PowerPoint.
If the role sounds interesting to you, please contact '' to understand more on the role. Please indicate the position that you are interested in the subject heading.

*Only Singapore Citizens and Singapore Permanent Residents may apply.

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