• Support the care team to better integration and coordinate patients' care across care continuum
• Collaborate with multi-disciplinary team members to provide comprehensive care and advocate care option and services for patients and families with complex psycho social needs.
• Be a care buddy for patients.
• Case Management
• Screen patients for their bio-psycho-social, environmental, vocational and financial needs
• Interview patients and families' health beliefs/attitudes that influence their views on health and health seeking behaviors
• Gather information of the patients and families' social support system and other socioeconomic resources that can impact patient's health and care
• Synthesize gathered information to identify the predisposing factors of the patients' bio-psychosocial needs and discuss with the care team to prioritize patients' care needs
• Work with the care team to plan and effect the patient's care plan e.g. lifestyle and behavioral health modification... medication, self-monitoring, self-care adherence, psycho-social needs etc.
• Understand patients and families' health literacy to enable them to be able to understand the care team's care plans.
• Assess patients and families' confidence in ability to carry out the health behavior change and provide the continuous support (buddy) and motivate patients to achieve their health goals
• Follow-up, monitor and evaluate the patients' coping ability at home and escalate issues identified with patients and families to care team
• Perform regular follow-up calls to patients with poorly controlled chronic conditions and/or with complex psycho-social issues
• Assist home assessment/visit with Medical Social Worker for poorly control chronic patients with complex psycho-social issues, if only needed
• Act as the "Point of Contact" to integrate the complex patients' care vertically and horizontally beyond the primary care setting. Be a social health integrator for the care teams, community partners and hospitals.
• Engage, Educate and Empower patients and families in their care
• Educate patients and families to understand how their behavioral health factors can affect their health and illness
• Use strong interpersonal skills to help patients feel comfortable and motivated, and build therapeutic relationship with patients and families
• Communicate effectively to ensure patients and families are able to access, understand and use information. Provide appropriate health materials to reinforce information provided during clinic visits.
• Health Education and Community Involvement
• Assist in organizing and preparing of the support workgroups, workshops and activities.
• Participate actively in community outreach programmes.
• Risk and Quality Management
• Adhere to the International Patient Safety Goals and infection control practices.
• Comply with guidelines and safe practices according to organizational Work Instructions and Policies.
• Maintain a clean and safe working environment
• Participate in continuous quality improvement activities.Requirements
• Min Degree in health-related fields. Possess working experience in healthcare or social care sectors preferably in case management
• Dynamic, resourceful and proactive in approach to work and challenges.
• Possess a "can do" attitude, as well as good planning and organizational abilities
• Self-motivated, result –oriented and can work independently
• Excellent interpersonal, communication and coordination skills. For interested candidates, please send your most recent and updated resume to ************

Subject heading: Comm Care Exec

Michelle Lee Ser Min

(R1440070)

Recruit Express Pte Ltd

EA License No. 99C4599
Singapore

Salary Criteria