Care Consultant, Care Transition

The Agency for Integrated Care (AIC) aims to create a vibrant care community for people to live well and age gracefully. AIC coordinates and supports efforts in integrating care to achieve the best care outcomes for our clients. We reach out to caregivers and seniors with information on staying active and ageing well, and connect people to services they need. We support stakeholders in their efforts to raise the quality of care, and also work with health and social care partners to provide services for the ageing population. Our work in the community brings care services and information closer to those in need. For more about us, please visit https : / / www.aic.sg.

Being part of the Care Transition team, the Care Consultant plays a vital role in assisting clients and caregivers in navigating the complexities of health and social care systems.

The job scope includes :

• Review and analyse clients\' records and aplication history to understand their care related history and status.
• Conducts interviews with clients to gather information on their medical, functional, cognitive, psychological, social, environmental, and financial needs in various settings, including hospitals, clients\' homes, and other pertinent locations.
• Perform relevant assessments e.g., interRAI, Residential Assessment Form (RAF), Functional Assessment Report (FAR), Modified Barthel Index (MBI), Abbreviated Mental Test (AMT), Clinical Frailty Scale (CFS) and other relevant assessment tools.
• Leverage on the assessment done by other health professionals such as Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS) and other relevant assessment tools, to gather essential information on clients.
• Apply clinical reasoning and critical thinking to interpret assessment findings and identify issues, including red flags that require intervention.
• Collaborate with multidisciplinary teams, including clinicians, social workers, and caregivers, to discuss issues and formulate or refine care plans for optimal outcomes.
• Implement interventions to manage identified issues and red flags, ensuring that clients receive appropriate care and support.
• Share, promote and administer MOH and other agency initiatives, campaigns, programmes, services, schemes and grants and facilitate the application.
• Advocate for clients\' and caregivers\' preferences and address their expectations while ensuring compliance with clinical and operational guidelines.
• Educate clients and caregivers on managing clients\' conditions to enhance their ability to engage in self-care and cope effectively within the community.
• Serve as a resource and point of contact for clients and caregivers, building and maintaining strong relationships.
• Refer clients to appropriate healthcare providers and community care partners based on their needs.
• Assist and contribute as a subject matter expert for the continuous improvement of systems, processes, and services.

Job Requirements

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