Senior Wellbeing Coordinator, (PHIC - ICCS)

Job Detail

The Senior Wellbeing Coordinator (SWBC) is responsible for collaborative work with the Patient Navigator (PN) and the interdisciplinary healthcare team in providing effective, integrated and person-centered health and social care to patients and caregivers as they transition from acute hospital to community. The SWBC shall contribute to patient’s care plan, recommend, and coordinate the social integration aspects of discharge planning and act as a liaison person between patient, family members, the multidisciplinary team (MDT), institution and external agencies in the community The SWBC shall perform initial basic health screening and social care needs assessment in respective hospital sites Develop and implement patient's care plans in a timely and coordinated manner Ensure continuous monitoring and regular follow-up with the PN/ interdisciplinary care team, patient and caregiver on the discharge care plan Review the discharge care plan with PN when there is a change in the patient’s care needs or medical condition Reinforce basic patient and caregiver education/training on a need's basis Provide basic coaching and empowerment on self-management at home when necessary