A heart failure Case Management Officer assesses, plans, coordinates, monitors and evaluates care plans for heart failure patients and their families with the aim of fostering quality, continuity and appropriate utilization of health care resources throughout the continuum of care during the patient's life span. The case manager facilitates and coordinates the utilization resources for maximization of health and financial outcomes, as well as patient/family satisfaction. The case manager also collaborates proactively with all disciplinary team members with a patient focus to facilitate and maximize healthcare outcomes.

Job Responsibilities

Case management and Disease management
Conducts assessment of patients for medical, psychological, social, environmental, vocational and financial needs.
Formulates plans of patient care in collaboration with clinicians and other health care members.
Work independently within the guidance established by the clinical departments protocols, policies and practices for the care, comfort and safety of patients.
Quality/ Outcomes management
Assists in formulation and revision of guidelines, standards and procedures.
Participates in research studies for the discipline or across disciplines.
Participates in quality improvement committees.
Education
Conducts education sessions to healthcare staff on Heart Failure Programme
Conducts education sessions for patients to promote Heart Failure self-care management.
Conducts brief smoking cessation counselling to Heart Failure patients who are smokers.
Collaborates with Disease Management workgroup to develop educational materials for Heart Failure.
Participates in outreach programmes to promote awareness of heart failure and self management.
Telemanagement
Tracks patient's health progress through regular telephonic contacts as per protocol.
Handles telephone calls and enquiries from patient and caregiver
Heart Failure Clinic
Conducts patient assessment of vital signs, signs and symptoms of Heart Failure.
Assess and recruits eligible patients into various disease programmes and services.
Conducts quality of life and other surveys for Heart Failure patients.
Monitors and track clinic attendance and default rate.
Monitors and reviews influenza and pneumococcal vaccination schedule for chronic heart failure patients.
Monitors and reviews regular cardiovascular risk factor screening.
Assists doctors and pharmacists with anticoagulation management.
Coordinates patient appointments with other clinics and services.
Identifies patients with special needs such as depression and socioeconomic difficulties.
Advanced Care Planning (ACP)
Identifies suitable Heart Failure patients for ACP sessions.
Facilitates ACP sessions.
Telehealth Weight Monitoring
Accesses and identifies suitable patients for telehealth weight monitoring.

General

Participates in QC and other projects as directed by department or hospital
Facilitates and coordinates step-down appointments to NUHP/FMC according to existing protocol
Participates in inhospital, community, regional or national activities as directed by the hospital or department.
Undertakes assignments as directed by the Department of Cardiology, National University Heart Centre, Singapore
Critically evaluates the activities and practice patterns of the heart failure case managers.
Precepts, coaches and counsels juniors in their work, patient safety and risk management activities.
Facilitates team dynamics and the smooth running of activities in the unit.
Supports new initiatives/ lead changes implemented by departments.

Job Requirements

Bachelor Degree in Nursing/ Science
A relevant post-basic qualification in the specialty is an added advantage
Registered Nurse with at least 5 years of clinical experience in Nursing, of which a minimum of 2 years
A critical thinker, self-motivated and able to work as part of a multi-disciplinary team.
Good interpersonal and communication skills.
Good supervisory and coaching skill.

(Senior) Case Management Officer (Heart Failure)