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Manage ESRD patients in dialysis centre or home dialysis (HD/ PD) through client engagement, conducting interviews, data collection, case assessment (BPSS, risk & needs assessment and other relevant assessment tools), case conceptualisation, case planning and intervention plans for best patient outcomes.
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Identify presenting/underlying issues and problems to design a care plan to enhance/maintain and promote psychosocial functioning of patients.
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Conduct FFRs (Financial Fee Reviews) and placement on NKF subsidies and welfare programmes.
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Conduct visits to dialysis centre, home or hospitals to provide supportive counselling.
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Advocate for the protection of patient's dignity, confidentiality and rights
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Collaborate with healthcare professionals professionally internally and externally in total patient management.
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Network with government, community, social agencies or individuals to mobilise social resources to meet patient's needs.
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Facilitate patient and caregiver support group programmes.
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Document biodata of patients and interventions in clinical system for records, complete timely online case documentations (Case session recordings, follow-up recordings, risk and needs assessment, social reports, patient feedback forms etc)
