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.

Requirements

• Degree in Social Work or equivalent (recognised by SASW)
• Relevant experience in medical or community social work preferred
• Strong interpersonal, communication and organisational skills
• Ability to work collaboratively in a multidisciplinary setting