Medical Social Worker

Role Overview:

Work alongside a multidisciplinary team (MDT) of specialist doctor, nurses, allied health and community volunteers to provide social work services and programmes to ESRD patients in need and their families.

Key Duties & Responsibilities

• Case Admission and Assessment
  • Manage the referral process for the dialysis centre, including intake screening, admission, financial counselling, slot placement, and orienting new patients into the centre.
  • Conduct needs assessment for all referrals, formulating tailored care plans for patients and their families.
  • Collaborate closely with referral partners and the multidisciplinary team to facilitate smooth care transitions for patients.
  • Provide supportive accompaniment to patients as they adapt to and settle into the dialysis centre environment.
• Case Management
  • Conduct regular check-ins with patients during dialysis sessions to monitor well-being and maintain therapeutic rapport.
  • Work closely with MDT and volunteers to identify and flag patients at risk of psychosocial deterioration, treatment non-adherence, or financial hardship for early intervention.
  • Conduct home visits or hospital visits where necessary for a more holistic understanding of patients’ needs and care planning.
  • Develop, implement, and regularly review care plans for patients identified as high-risk or complex cases.
  • Connect patients with appropriate community resources and advocate on behalf of patients to address barriers to care
• Programme Planning and Implementation
  • Plan, design, and implement patient-centred programmes and psychoeducation sessions with a focus on improving quality of life, well-being, and social integration.
  • Coordinate programme logistics including venue arrangement, registrations, volunteer mobilization and engagement of facilitators or speakers.
  • Continuously monitor and evaluate programme effectiveness, gathering feedback from participants and stakeholders to drive ongoing improvements.
• Volunteer Engagement and Supervision
  • Serve as the primary point of contact for befriender volunteer group, providing training to new and existing volunteers as required.
  • Review volunteer befriending records periodically, following up closely with volunteers on cases requiring social service attention or intervention.
  • Coordinate volunteer involvement in relevant social service programmes, events, and outreach activities.
  • Provide regular supervision and ongoing support to befriender volunteers to ensure safe and effective service delivery.
  • Support management in volunteer engagement initiatives to cultivate a committed volunteer pool
  • Provide management with feedback on volunteer performance, highlighting areas for improvements for the befriending programme.
    
• Documentation and Reporting
  • Maintain timely and accurate case records in accordance with organisational and professional standards.
  • Prepare periodic reports on the progress of social services and programmes for management review
  • Support audits processes by providing required documentation and participating in review exercises.