Medical Social Worker (Home Care)

Responsibilities and Duties:

· Conduct psychosocial assessments to identify patient’s needs, strengths, risks and challenges within the home and community environment.

· Collaborate with patients, caregivers and relevant community partners to develop and implement individualized care plans that facilitate safe transition and continuity of care from hospital to home.

· Participate actively in multidisciplinary team meetings to discuss, coordinate and review patient care plans.

· Organise and participate in case conferences with relevant agencies and community partners to facilitate coordinated care and service integration.

· Provide emotional support and supportive counselling to patients and caregivers to address adjustment, coping, caregiving stress, and psychosocial concerns.

· Facilitate group sessions for patients and caregivers to provide shared learning and support, where appropriate.

· Assist patients and families in accessing available community resources, financial assistance, social support services and relevant schemes.

· Conduct home visits and follow-up interventions to monitor progress, assess ongoing needs and provide continued support.

· Maintain accurate and timely documentation of assessments, interventions, care coordination and follow-up plan in the relevant clinical systems in compliance with organizational and regulatory requirements.

· Support and participate in service development, quality improvement initiatives and community-based programmes aimed at enhancing patient and caregiver support.

Job Requirements:

· Degree in Social Work, preferably with 2 or 3 years of relevant social work experience.

· Prior experience in a healthcare or Social Services Agencies will be advantage.

· Registration with Social Work Accreditation Board is preferred.

· Must have an interest in working with seniors and their caregivers.

· Must be able to work independently and collaboratively within a multidisciplinary team.

· Good interpersonal, communication and case management skills.