Care Coordinator

Job Description:
The Care Manager supports and works within the Hospital, and collaborates with patients 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 the Hospital within the community.

**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 patients 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 patients 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 patients lifestyle in the community.
- Monitor patients general medical condition during home visit and report to patients 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 patients 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 the 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.
- Organized, 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.
- Need nursing background
- 5 days work week

Job ID:
LRW5386X

**People Profilers Pte Ltd**

20 Cecil Street, #08-09, Plus Building, Singapore 049705

Tel: 69509745

EA Licence Number: 02C4944

EA Registration Number: R1108448

EA Personnel: Tan Lili Gesse