The role is responsible to work collaboratively with the interdisciplinary care team and community care partners to provide holistic care and support to clients in the community. To provide accurate and timely documentation of patient assessment, care plan, interventions rendered and evaluation. Able to refer/escalate to appropriate healthcare providers / community care partners according to patient's needs based on pre-defined protocols or guidelines.

 

The role is responsible for working collaboratively with the interdisciplinary care team to provide acute hospital-level nursing care and support patients in their homes. The staff roles involve conducting clinical assessments, administering treatments, developing and implementing care plans, and provide patient and family education. The staff supports early discharge from hospital for patients where acute hospital-level care can be administered safely at patient homes in accordance with hospital regulations and licensing.

 

• Identify patients requiring telecare interactions.

• Perform comprehensive assessment for medical, functional, cognitive, psychological, social, environmental and financial needs to identify issues for interventions.

• Provide patient and family education in managing the patients' disease in accordance to approved National Guidelines.

• Make appropriate referrals according to patients' needs.

• Document care plan timely and accurately.

• Participate in teaching and training professional development of telecarers related knowledge and skills.