Medical Social Worker

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.

• →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.