Case Management Officer - G-RACE (Contract)

Job Description

The job holder is responsible to work with the Multi-Disciplinary Team (MDT) to ensure the continuity of holistic patient care, by assessing and evaluating needs of the patient and caregivers, and planning, coordinating, implementing and monitoring the interventions to address those needs.

The Challenges

Primary Responsibilities and Duties

• Respond to inquiries on referral to G-RACE Home Clinic or Allied Health Intervention (Home-Based).
• For accepted referral assigned to job holder, arrange for home visit date, time and venue with patient / family.
• Open a G-RACE case folder with appropriate forms and assessment scales for each patient assigned.
• Carry out home visit on planned date and time.
• Establish rapport and build therapeutic alliance with patient and family.
• Conduct assessment for patient regarding physical, medical, psychological, social, environmental and financial needs, including monitoring of mental state examination, monitoring signs of relapse and caregiver stress.
• Provide home intervention and psycho-education to patient and family in response to needs identified at the home visit.
• List down patient’s / family’s needs or problems and formulate individualised care plan. Discuss the care plan with doctor in charge or other members if deem necessary.
• Update the team during MDT meeting the findings of the home visit and follow-up on action plan agreed in the meeting.
• Recommend or execute recommended strategies to reduce patient’s hospital readmission rate and caregiver stress.
• Continue to support the patient / family through home visits and phone calls until the team approved to discharge the case from G-RACE Service.
• Refer patient / family to appropriate community resources as appropriate.
• Maintain infection control practice during home visits.
• Document home visits (including those visits at community social agencies or other clinics) and phone calls follow-up in patient’s G-RACE case folder.
• Participate in regular multi-disciplinary meetings.
• For patients referred to primary care, provide education and counseling to patient / family, consolidate outpatient clinic appointments as appropriate and follow-up with first visit at primary care clinic.
• Establish linkages with community social agencies and primary care partners.
• Conduct training for the staff or volunteers of partnering social agencies to better understand the various psychogeriatric issues and disorders.
• Perform assessment for elderly who might be at risk of mild cognitive impairment, dementia or depression in the community.
• Assist Reporting Officer to coordinate or conduct training, workshops or talks for partnering social agencies and caregivers of G-RACE’s patients.

Secondary Responsibilities and Duties

Job Requirements

Qualification :

Experience :

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