Care Coach

Institution:  National Healthcare Group Polyclinics
Family Group:  Ancillary

Job Description


Care Coach supports the care team to better integration and coordinate patients’ care across care continuum. Collaborate with multi-disciplinary team members to provide comprehensive care and advocate care option and services for patients and families with complex psycho social needs. Be a care buddy for patients.



Case Management

- Screen patients for their bio-psycho-social, environmental, vocational and financial needs

- Interview patients and families’ health beliefs/attitudes that influence their views on health and health seeking behaviors

- Gather information of the patients and families’ social support system and other socioeconomic resources that can impact patient’s health and care

- Synthesize gathered information to identify the predisposing factors of the patients’ bio-psychosocial needs and discuss with the care team to prioritize patients’ care needs

- Work with the care team to plan and effect the patient’s care plan e.g. lifestyle and behavioral health modification, medication, self-monitoring, self-care adherence, psycho-social needs etc.

- Understand patients and families’ health literacy to enable them to be able to understand the care team’s care plans.

- Assess patients and families’ confidence in ability to carry out the health behavior change and provide the continuous support (buddy) and motivate patients to achieve their health goals

-  Follow-up, monitor and evaluate the patients’ coping ability at home and escalate issues identified with patients and families to care team

-  Perform regular follow-up calls to patients with poorly controlled chronic conditions and/or with complex psycho-social issues

- Assist home assessment/visit with Medical Social Worker for poorly control chronic patients with complex psycho-social issues, if only needed

- Act as the “Single Point of Contact” to integrate the complex patients’ care vertically and horizontally beyond the primary care setting. Be a social health integrator for the care teams, community partners and hospitals.


Engage, Educate and Empower patients and families in their care

- Educate patients and families to understand how their behavioral health factors can affect their health and illness

- Use strong interpersonal skills to help patients feel comfortable and motivated, and build therapeutic relationship with patients and families by using appropriate language (health literacy) and approach (motivational interviewing) that helps overcome barriers

- Communicate effectively to ensure patients and families are able to access, understand and use information. Provide appropriate health materials to reinforce information provided during clinic visits. 


B. GENERAL (20%)

Health Education and Community Involvement 

- Assist in organizing and preparing of the support workgroups, workshops and activities.

- Participate actively in community outreach programmes.


Risk and Quality Management

- Adhere to the International Patient Safety Goals (IPSG) and infection control practices.

- Comply with guidelines and safe practices according to organizational Work Instructions and Policies.

- Maintain a clean and safe working environment

- Report unsafe practices and incidences in accordance to NHGP quality standards

- Participate in continuous quality improvement activities.


Professional Development

- Attend appropriate training courses to acquire new knowledge and skills.

- Assess own learning needs and undertake learning as appropriate.


Resource Management

- Demonstrate proper use and care of the clinic equipment and consumables. 



Perform other duties as assigned by the supervisors. 


Special Attributes and Knowledge

- Dynamic, resourceful and proactive in approach to work and challenges. 

- Possess a “can do” attitude, as well as good planning and organizational abilities

- Self-motivated, result –oriented and can work independently

- Excellent interpersonal, communication and coordination skills.