- Conduct biopsychosocial and environmental assessments to identify patient and caregiver needs. Assess patients' needs via telephonic or video consultation and determine appropriate interventions or home visits.
- Develop, implement, and evaluate person-centred care plans and interventions.
- Deliver evidence-based nursing interventions
- Ensuring: patient dignity, safety, confidentiality, and advocacy.
- Participate in joint visits or video consultations with physicians when required.
- Coordinate patient care with the attending physician and multidisciplinary team (MDT) for seamless service delivery.
- Serve as a liaison between patients, families, and healthcare professionals to ensure effective communication and continuity of care.
- Conduct follow-ups to monitor post-visit conditions, adherence to treatment plans, and recovery progress.
- Facilitate and participate in MDT meetings and case discussions to optimize patient outcomes.
- Develop discharge plans and coordinate referrals.
- Supervise Staff Nurses, Enrolled Nurses and nursing students to meet learning objectives.
- Empower clients and caregivers through education, health promotion, and skill-building.
- Provide end-of-life care support, including advance care planning (ACP) and bereavement care.
- Promote infection control and patient safety practices, including proper use of PPE and aseptic techniques.
- Follow organizational and legal requirements for storage, handling, and control of drugs, medical equipment, and supplies.
- Ensure compliance with confidentiality and data protection policies.
- Practice resource stewardship and cost-effective care.
- Maintain accurate and timely documentation.
- Assist Nurse Manager/Nurse Clinician in audits, complaints handling, and process improvements.
- Engage in continuous professional development and quality improvement projects.
- Plan and manage patient workload using scheduling tools.
- Cover home care services as assigned, including cross‑coverage, after‑hours, weekends, and public holidays.
- Support financial processes, including fee collection and healthcare scheme applications.
- Perform any other duties as assigned by the reporting officer.
Qualifications
Degree in Nursing and/or Advanced Diploma in Palliative Care or other specialty preferred with at least 5 years of experience in acute or community care setting.
Other Information
The incumbent is responsible for delivering high‑quality home nursing care, conducting comprehensive assessments, and implementing evidence‑based interventions. The role includes supervising nursing staff, collaborating with multidisciplinary teams, and ensuring patient safety, dignity, and continuity of care. Acts as a resource and mentor while supporting quality improvement initiatives and end‑of‑life care.