Co-ordinate an assessment onsite of patient to assess nursing/rehab status/behavioural and any social concerns.
Review social aspects in ward with regards to activity participation, visitors and befriending, financial consideration status, etc.
Provide therapy/nursing/medical/social recommendations and support family and resident to complete home discharge or other care options.
Review supporting documents for referral to other care options and seek financial assistance for home equipping as recommended by therapist where required.
Provide counselling to patients with psychosocial issues.
Facilitate family conference for discussion on financial considerations, if necessary.
Work with Nursing team to review care to residents and understand their social situation.
Work with resident or next-of-kin on financial considerations (e.g. Government Means Test subsidy).
Review cases and facilitate meetings for Medifund cases.
Apply for financial assistance (e.g. Means Test, Medifund, IDAPE, ELDERSHIELD, MFEC).
Update residents’ profile and movement in database.
Manage and supervise team members in case management team.
Guide on the professional development of team members.