Care Manager

1 week ago

Singapore NATIONAL UNIVERSITY HEALTH SYSTEM PTE. LTD. Full time

Overview


Supports and works within Alexandra Hospital, providing with administrative support and collaborates with 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 enable early detection of deterioration and faster access to care.

To assist in supporting patients and their family members in navigating their healthcare journey with Alexandra Hospital within the Queenstown community.

This role also requires knowledge in evidence-based preventive health interventions, in areas of primary (lifestyle), secondary (detection and vaccination) and tertiary (management) prevention.

The knowledge is applied to manage the health of defined at-risk populations both in the hospital and out in the community, helping to facilitate broader cluster goals of an upstream preventive health approach to delaying onset of frailty and chronic conditions.


Responsibilities

You will be responsible for the following**:
AH Community Nodes

  • Regularly station in community healthcare posts when needed, where patient/ residents can be cared for conveniently within their community.
  • Coordinating and providing care activities in the community health posts, including performing basic health screening and health assessments, and providing health education/counselling to patients/residents with chronic diseases, on home monitoring devices and preventive lifestyle modification education
  • Being deployed at community touchpoints, e.g. SACs, RCs, CCs, to enrol participation, communicate and promote upstream preventive health, and other relevant care programmes that are suitable for resident/patient.
  • Managing the evidencebased scheduling and uptake of preventive health interventions for enrolled residents/patients.
  • Coordinating and scheduling of interventions and make referrals to national programmes such as Screen For Life (HPB)
  • Motivating residents/patients to take up preventive health interventions and seek appropriate care.
  • Working with community partners to enrol and manage atrisk residents
  • Conduct and support health education talks developed by the department to facilitate education of residents in the community and their subsequent enrolment to relevant health programmes
  • Understand the various ranges of services and available options in the patient's community and coordinate the necessary referrals accordingly and in a timely manner. Be able to explain to patients and caregivers the options and encourage enrolment.
  • Following up with care providers and clinical teams on completion of interventions.
  • Work with community service partners on care plans if necessary, and when there are variances in medical care plans.
  • Provide a valuable link by ongoing collaboration among the patients, families/caregivers and the multidisciplinary teams on a timely basis.
  • Connecting residents/patients to AH Virtual Care Centre (longer term) to support stepup model of care, e.g. teletriaging, for atrisk groups.
Care & Case Management

  • Recruit high risk patients through multiple platform; via inpatient MDMs, direct referrals, and/or discharge screenings, etc.
  • Work with Senior/Care Managers to assess patient's medicalnursing, psychosocial, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
  • Understand the various ranges of services and available options in the patient's community and coordinate the necessary referrals accordingly and in a timely manner. Be able to explain to patients and caregivers the options and encourage enrolment.
  • Provide a valuable link by ongoing collaboration among the patients, families/caregivers and the multidisciplinary teams on a timely basis.
  • Conduct followup telephonic reviews and/ or conduct home visits to ensure smooth coping of patients and caregivers in the community.
  • Promote and guide positive changes in patient's lifestyle in the community.
  • Monitor patient's general medical condition during home visit; update Care Manager and report to patient's Principal Doctor or primary care provider and/or community partner where necessary.
  • Be an advocate for advanced care planning initiatives; linking patients and their families for ACP conversation with relevant community partners.
  • Tracks and monitor team's database to ensure timely and accurate updates for recruited patients.
  • Assist team in appointment creation, actualization and billing if required.
Referral Management

  • Understands the inclusion and exclusion criteria for community case and transitional care referrals. Triage all referrals received via the hospital messaging system and allocate appropriate patients to members within the One with Community Team.
  • Updates database in an accurate and timely manner. Followup with assignment of referral to the relevant Care Manager where appropriate.
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