Medical Social Workers (MSW) are trained to provide a holistic approach to residents healthcare needs. They work closely with the Agency for Integrated Care (AIC) on the referrals from hospitals to the Home and also establish close liaison with other voluntary welfare organisations (VWO) to ensure high quality care for residents and their families.

They attend to the social, environmental, financial and emotional needs of patients and families across the continuum of care offered by the various programmes and services eg.

Referral

• Assessment of all Referrals for admission / rejection
• Pre-admission counseling to ensure both resident and families to understand better the Home’s background, its facilities and services, the various rules & regulations etc
• The Application procedures for government subsidy
• Means Testing

Discharge and Follow up services

• Participate in the Discharge Care Plan of residents
• Placement of Discharged residents in sheltered homes
• Arrangement for Home Care services & special needs
• Coordination of care plan after discharge to facilitate integration of the resident with his family and community

Psychosocial

• Counseling for enhancing cognitive, emotional, interpersonal and/or social functioning
• Increasing the resident’s & family’s understanding of an illness, treatment plan or grief
• Follow-up on psychosocial adjustment of resident on discharge

Financial Assistance

• Provide information on financial assistance & community resources e.g. IDAPE, Medifund, Eldershield, DPS etc
• Assistance with payment of nursing home charges & short-term financial support to patients

Community Resource Education and Referral

• Provide information & education on community resources & options available to meet identified needs of residents and families
• Facilitate referrals to community agencies to ensure access to appropriate resources & continuity of care