Medical Social Worker (ReAblement Programme) (3-Year Contract)

HYPERSCAL SOLUTIONS PTE. LTD.; Singapore; On-site; SGD 60,000 - 90,000; Full time

Job summary

Home Nursing Foundation in Singapore is seeking a Social Worker to lead psychosocial assessments, develop care plans with Occupational Therapists, and support clients and caregivers through the ReAblement journey over a 12-week programme.

You will coordinate with community partners, conduct reviews, and facilitate discharge planning while providing stress and grief support as needed; a degree in Social Work and at least 2 years of medical social work experience are required.

Qualifications

• Degree in Social Work or a Graduate Diploma in Social Work.
• Minimum 2 years of relevant experience in Medical Social Work, preferably in community care, rehabilitation, or home-based intervention programmes.
• Demonstrated experience working within an interdisciplinary team, conducting client/family assessments, and coordinating care with community partners.

Responsibilities

• Lead home visits with Occupational Therapists during intake and conduct psychosocial assessments.
• Collaborate with OT to co-develop client-centered care plans aligning functional and psychosocial goals.
• Conduct scheduled reviews to monitor progress and address barriers to behaviour change.
• Develop Befriender Buddy volunteer scheme within assigned subregions and recruit volunteers.
• Coordinate and assign tasks to RCAs delivering interventions and match clients with Befriender Buddies.
• Introduce social prescription and linkage to community activities, accompanying clients for first visits.
• Support client and caregiver understanding of the ReAblement process and provide stress support when needed.
• Facilitate interdisciplinary team meetings to ensure coordinated, whole-person care.
• Document assessments, progress notes, and discharge plans accurately and timely with relevant records.
• Work with ICCP partners to ensure continuity of care beyond the programme.
• Support programme reporting and collaboration with Home Therapy team to meet outputs.

Skills

Interdisciplinary teamwork

Care coordination

Client engagement

Multilingual communication (Malay/Mand

Education

Bachelor in Social Work

Graduate Diploma in Social Work

Job description

COMPANY DESCRIPTION

Founded in 1976, Home Nursing Foundation (HNF) is a leading charity that provides home healthcare services in Singapore, regardless of our patients' ability to pay. Dedicated to all-round support for our patients, HNF delivers comprehensive care programmes to look after patients' emotional well-being and healthcare needs.Our HNF Wellness Day Care & Rehabilitation Centres offer an array of social activities, social support and holistic healthcare services to help our elderly stay independent in their own community.

RESPONSIBILITIES

• Lead home visits jointly with the Occupational Therapists (OT) during intake, conducting psychosocial assessments, identifying clients' community participation goals, and eliciting motivations to anchor the community reintegration journey.
• Collaborate with the OT to co-develop client-centered, goal-oriented care plans that align functional and psychosocial goals with the client's motivations.
• Conduct scheduled reviews to monitor progress on case management needs, reinforce goals in alignment with the client's motivations, and apply motivational interviewing to address barriers to behavioural change.
• Develop the Befriender Buddy volunteer scheme within assigned subregions (i.e. Hougang & Serangoon) - sourcing and recruiting volunteers from the community, onboarding them, co-facilitating training with the OT, and providing ongoing support to Befriender Buddies, in partnership with community stakeholders.
• Coordinate and assign tasks to ReAblement Care Associates (RCAs) delivering the intervention, and match each client with a Befriender Buddy.
• Introduce social prescription and begin linkage to community activities and groups of the client's choice, accompanying clients for their first visit where needed.
• Support client and caregiver understanding of the ReAblement process, providing stress and grief support to caregivers where needed, and addressing broader case management needs, motivations, and barriers to community reintegration, including facil...
• Support the formation and continuity of social and community groups, and continue linkage to these groups through to programme close-out.
• Support discharge planning towards the end of the programme, including helping clients fulfil their goals where achieved, and contribute to scheduling 6- and 12-month follow-up touchpoints.
• Facilitate interdisciplinary team meetings and case discussions with the OT, RCAs, and Befriending Buddies to ensure coordinated, whole-person care throughout the 12-week programme.
• Document assessments, progress notes, and discharge plans accurately and in a timely manner, including relevant case management and psychosocial records.
• Work closely with ICCP community partners - including AACs, home care providers, and social care providers - to ensure continuity of care beyond the programme.
• Support programme reporting and work closely with Home Therapy team to achieve programme outputs and outcomes.

QUALIFICATIONS

• Degree in Social Work or a Graduate Diploma in Social Work.
• Minimum 2 years of relevant experience in Medical Social Work, preferably in community care, rehabilitation, or home-based intervention programmes.
• Demonstrated experience working within an interdisciplinary team (e.g. with OT), conducting client/family assessments, and coordinating care with community partners.
• Passionate in supporting clients' functional recovery, community reintegration, and caregiver/family well-being.
• Ability to communicate with clients in Malay, Mandarin, Tamil and/or local dialects would be advantageous, as the role involves supporting clients from diverse language backgrounds.

Please note that your application will be sent to and reviewed by the direct employer - Home Nursing Foundation