• Full Time
  • West

Job Responsibilities*

You will be responsible for the following:

  • Assess and identify potential care gap or red flag that inhibits smooth transition from hospital to home and community.
  • Triage and assess patient’s medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
  • Synthesize assessment information to prioritize care needs and develop care plan and goals together with patient and/ or family/caregiver; with discussion with patient’s care team as well as community partners involved( if any).
  • Initiate conversation and discussion with patient, if required, to understand their available social care support system in order to identify potential care gap post-discharge/ post clinic consultation.
  • Trigger earlier intervention and suggest suitable referral to transitional care and community support services to support patient in community and home
  • Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient’s community. Coordinate and follow up referrals outcome accordingly and in a timely manner.
  • Adopt a multi-disciplinary approach with focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individual to address social and health issue
  • Conduct follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.
  • Promote and guide positive changes in patient’s lifestyle in the community.   
  • Monitor patient’s general medical condition during home visit and report to patient’s Principal Physician or primary care provider and/or community partner where necessary.
  • Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.
  • Document assessments, plans, and outcomes promptly and accurately in the relevant system. 
  • Maintain high level contact with step-down facilities.
  • Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient’s best interests.
  • Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.
  • Participate in projects and/or community events organized by hospital
  • Any other duties as assigned by Reporting Officer.   


  • Degree or equivalent professional qualifications in Nursing, Social Work or Allied Health profession.
  • 3 – 5 years of experience in healthcare settings is preferred.
  • Knowledge in geriatric and community care will be an advantage.
  • Strong team-player, with natural ability to interact with healthcare staff and community partners of all levels.
  • Organised, analytical, able to fit different pieces of the puzzle together.
  • Pleasant disposition, approachable, with strong interpersonal and relational skills.
  • Good verbal and written communication skills. Ability to use local languages and dialects will be an advantage, especially coupled with experience interacting with and managing patients and caregivers.
  • Independent worker, with strong initiative.
  • Comfortable with ambiguity, unchartered territory, enjoy challenges and problem solving. Enjoys continuous improvements and embrace changes to actualize new initiatives.
  • Equipped with basic computer skills in MS Words, Excel and PowerPoint.
Yeo Han Xiang Ryan 
Registration No: R1110362
EA Licence No: 04C5357