• Conduct psychosocial assessments to identify patient's needs, strengths and challenges in their home and in the community.

• Collaborate with patients, families and relevant organisations to develop and implement individualized care plans that facilitate the transition from healthcare facility to home.

• Actively participate in multi-disciplinary team meetings to discuss and coordinate patients' care.

• Organise and participate in case conferences with relevant organizations and community agencies to enhance patient care and service coordination.

• Provide emotional support and counselling services to patients and their families, addressing concerns and fostering resilience.

• Conduct group sessions for patients or caregivers to provide shared learning and support.

• Assist patients and their families in accessing available community services and support to meet their needs.

• Conduct home visits and follow-up sessions to address ongoing concerns and monitor progress.

• Maintain accurate and timely documentation of patient's care plans, interventions and coordination efforts within medical systems, ensuring compliance with healthcare regulations.

• Implement and support initiatives and programmes to enhance the care and support of patients and their caregivers within the community.

Job Requirements :

• Degree in Social Work, preferably with 1 to 2 years' social work experience.

• Experience in a healthcare or Social Services Agencies will be advantage.

• Registration with Social Work Accreditation Board is preferred

• Must have an interest in working with seniors and their caregivers.

• Must be able to work independently.