Responsibilities and Duties: To conduct post discharge follow-up (via phone call and/or home visit) to ensure patients and caregivers’ ability to cope with home care by helping to streamline and coordinate the range of community services available To be able to assess, analyze, recommend and implement strategies to address patient’s post-discharge care needs To help patients and their families to plan for and improve end of life care (for patients with terminal illnesses) To network with other partners in ILTC setting to enhance continual support to patients and their families post discharge from community hospitals so as to ensure optimum health outcomes Participate in hospital activities that contribute towards improving the quality of patient care e.g. research or innovative projects that enhance patient care To be an advocate for patients and their families Main point of contact between patients, families and the healthcare team Develop generic care management tools to coordinate care for patients Identify, analyze and address key problems in the holistic management of patients Assist in the preparation of reports and statistics as required Job Requirements: Professional qualification in Nursing, Social Work or Allied Health or/and any clinical discipline relevant to the job At least 3-5 years of clinical experience in nursing or related field in acute and /or community settings in Singapore