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

Home Nursing Foundation; Singapore; On-site; SGD 48,000 - 68,000; Full time

Job summary

Home Nursing Foundation in Singapore seeks a Medical Social Worker to lead psychosocial assessments during intake, align goals with motivation for community reintegration, and develop client-centered care plans with the OT. You will conduct reviews, support discharge planning, and engage with community partners to sustain progress.

The role emphasizes interdisciplinary collaboration, documentation, and culturally competent communication with clients from diverse language backgrounds.

Qualifications

• Bachelor's degree in Social Work or equivalent.
• Minimum 2 years of relevant experience in medical social work, preferably in community care.
• Experience coordinating care with an interdisciplinary team.
• Passion for functional recovery and caregiver well-being.
• Ability to communicate with clients from diverse language backgrounds would be advantageous.

Responsibilities

• Lead home visits with OT during intake, conduct psychosocial assessments and identify clients' goals for community reintegration.
• Co-develop client-centered, goal-oriented care plans with OT.
• Conduct regular reviews to monitor progress and address barriers to change.
• Develop Befriender Buddy volunteer scheme and recruit volunteers with community partners.
• Coordinate tasks to RCAs delivering interventions and match clients with Befriender Buddies.
• Introduce social prescription and link clients to community activities.

Skills

Interdisciplinary teamwork

Motivational interviewing

Client-centered care

Diverse language communication

Education

Bachelor's degree in Social Work

Job description

• 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 facilitating home modifications and environmental adjustments.

• 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.

Qualification

• 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.