Care Coordinator

**Overview**

The Care Coordinator supports and works within Alexandra Hospital, 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 support patients and their family members in navigating their healthcare journey with Alexandra Hospital within the Queenstown community.

**Responsibilities**:
You will be responsible for the following**:

- Recruit high risk patients whom benefit from transitional care and case management support through Multiple Disciplinary Meetings, referrals, screenings
- 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 goals together with patient, family/caregiver and the community care team.
- Implement appropriate care coordination and transitional case management; and evaluate the outcomes accordingly.
- Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient’s community. Coordinate the necessary referrals accordingly and in a timely manner.
- Provide a valuable link by ongoing collaboration among the patients, families/caregivers and the multidisciplinary teams on a timely basis.
- Conducts 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 Doctor 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.
- Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient’s best interests.
- Assist and guide team to attend to queries receive via an integrated telephone hotline that forms a network for triaging patients, and provides an avenue to caregivers and community partners to connect with Alexandra Hospital for information relating to the health and well-being of patients and clients within Queenstown community espcially after patient's discharge.
- Station in community healthcare posts when needed, where patient/ residents can be cared for conveniently within their community.
- 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, Counselling and Psychology with at least 3 years’ experience are preferred.
- Those with Diploma for the above professional tracks and has at least 5 years of experience in related field in acute and/or community setting in Singapore will be considered.
- Knowledge in geriatric care, chronic diseases management, and experience in home healthcare and home personal care and other community services 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.
- Equipped with basic computer skills in MS Words, Excel and PowerPoint.
- Experience and ability to work shifts may be an advantage for specific roles within the team.