Senior Wellbeing Coordinator, (PHIC - ICCS)

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 wh...