Case Management Officer

5 days ago

Singapore National University Polyclinics Full time $60,000 - $80,000 per year
Case Management Officer - G-RACE (Contract)

Job ID: 7219

Job Function: Allied Health

Institution: National University Hospital

Job Description :

The job holder is responsible for working with the Multi-Disciplinary Team (MDT) to ensure the continuity of holistic patient care by assessing and evaluating the needs of patients and caregivers, and planning, coordinating, implementing, and monitoring interventions to address those needs.

The Challenges
Primary Responsibilities and Duties
  1. Respond to inquiries regarding referrals to G-RACE Home Clinic or Allied Health Intervention (Home-Based).
  2. Arrange home visit dates, times, and venues with patients and families for accepted referrals.
  3. Open a G-RACE case folder with appropriate forms and assessment scales for each patient.
  4. Conduct home visits as scheduled.
  5. Establish rapport and build a therapeutic alliance with patients and families.
  6. Assess patients' physical, medical, psychological, social, environmental, and financial needs, including mental state monitoring and signs of relapse or caregiver stress.
  7. Provide home interventions and psycho-education based on assessed needs.
  8. Document patient and family needs, formulate individual care plans, and discuss with the medical team as needed.
  9. Update the team during MDT meetings with findings and follow-up actions.
  10. Recommend strategies to reduce hospital readmissions and caregiver stress.
  11. Support patients and families through ongoing visits and calls until discharge approval.
  12. Refer patients and families to community resources as appropriate.
  13. Document all visits and follow-up communications in the patient's case folder.
  14. Participate in regular multi-disciplinary meetings.
  15. For primary care referrals, provide education, consolidate outpatient appointments, and follow up at primary care clinics.
  16. Establish linkages with community social agencies and primary care partners.
  17. Conduct training for staff and volunteers of partner social agencies on psychogeriatric issues.
  18. Assess elderly individuals at risk of cognitive impairment, dementia, or depression in the community.
  19. Assist in coordinating and conducting training, workshops, or talks for partners and caregivers.
Secondary Responsibilities and Duties
  1. Assist in data collection and maintaining a clinical pathway database.
  2. Provide monthly reports on key performance indicators.
  3. Evaluate and improve operational procedures and practices.
  4. Support implementation and evaluation of procedures or systems.
  5. Assist in research studies and collaborations involving G-RACE and partners.
  6. Perform other duties as assigned by supervisors.
Job Requirements:
Qualification:
  • Bachelor Degree in Psychology or Nursing.
  • Registered Nurse with at least 3 years of clinical experience, preferably with psychiatric experience.
Experience:
  • Good interpersonal and communication skills.
  • Proficient in IT applications.
  • Excellent oral and written communication skills are advantageous.

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