Care Coordinator - St. Andrew's Nursing Home (Aljunied)

STATEMENT OF PURPOSE

This role support and assist the nursing team and the medical social work team in the administrative tasks, information gathering, form filling, fieldwork and other ad hoc duties.

KEY RESPONSIBILITIES

1. Pre-admission/Admission Support

1.1. Orientate new residents and their NOKs to the nursing home

1.2. Ensure residents settle well in the nursing home.

2. Casework (non-complex case)

2.1. Engagement and Assessment

. Establish rapport and build professional relationship with resident and significant others

. Identify and clarify the key issues to the problem situation and gather relevant information from resident and NOKs

. Conduct bio-psycho-social-spiritual assessment to assess and identify the severity and key risks and protective factors for intervention

. Engage residents, families, multi-disciplinary team and relevant stakeholders to gather holistic and relevant information

2.2 Goal Setting and Intervention Plans

. Analyse and evaluate different courses of action, when appropriate with multi-disciplinary team and relevant stakeholders

. Formulate appropriate strategies for action

. Conduct care planning and goal setting with residents based on standard guidelines and professional assessments

. Set clear contracts and goals with residents - Engage residents to sustain effort in problem-solving

. Apply appropriate assistance schemes

. Collaborate and negotiate with stakeholders to mobilise community resources

2.3 Case Review and Documentation

. Follow up and review care plans and provide recommendations to modify care plans where necessary

. Evaluate the process as well as the outcome objectively and recommend future improvement

. Provide documentation and timely updates of assessments and intervention to be used by multi-disciplinary profession

. Work with MSWs on providing social reports with proper consent to relevant

stakeholders to ensure continuity of care

3. Keep residents meaningfully engaged

3.1. Understand interests of individual residents

3.2. Organise activities that are of interest to residents

3.3. Engage and motivate residents to participate in the activities

3.4. Work with volunteers and Volunteer Manager in activities planning and implementation

3.5. Review and evaluate the effectiveness of activities in improving the well-being of residents or handle the situation.

4. Support volunteer program

4.1. Provide feedback on possible new volunteering opportunities based on the needs observed on the ground.

4.2. Work closely with the Volunteer Manager on effective mobilising of resources to support volunteer program.

4.3. Activities Programme

. Provide supervision during implementation of activities

. Provide feedback to volunteers on areas of improvement via Corporate Communication in charge

5. Support Advance Care Planning (ACP) program

. Initiate ACP awareness with residents and their NOKs

. Facilitate General ACP or PPC with residents and their NOKs for those who are ready

. Review ACP plans regularly

. Assist residents in fulfilling their care preferences and last wishes.

ADDITIONAL DUTIES

1. The staff will undertake projects relevant to the post, as requested by HOD or ED.