Key Responsibilities

Psychosocial Assessment and Case Management

Conduct comprehensive psychosocial assessments for new and existing residents.

Identify residents' strengths, needs, preferences, and risks.

Develop, implement, and update individualized care and support plans in collaboration with families and care teams.

Counselling and Emotional Support

Provide individual and group counselling to residents and their families to support emotional well-being.

Address issues such as grief, loneliness, adjustment to nursing home life, or end-of-life concerns.

Facilitate conflict resolution and crisis intervention as needed.

Resource Coordination and Advocacy

Connect residents and families with appropriate community resources (e.g., financial assistance, legal aid, mental health services).

Act as a resident advocate to ensure their voice and preferences are heard and respected in care planning.

Liaise with external partners such as AIC, MSF, hospitals, and VWOs to support residents’ needs.

Discharge Planning and Care Transitions

Coordinate with families and external agencies to develop safe and effective discharge or transfer plans.

Assess post-discharge support systems and ensure follow-through with referrals (e.g., home care, transport, social support).

Provide education and preparation to caregivers and residents during transition.

Training and Education

Conduct talks or workshops on topics such as caregiving, mental wellness, advance care planning, and elder rights.

Support team members with training on psychosocial care principles and communication strategies.

Raise awareness among staff about the social aspects of aging and holistic care.

Documentation and Compliance

Maintain accurate, confidential, and timely records of all assessments, interventions, and outcomes.

Submit regular reports to support audits, program evaluation, and funding requirements.

Ensure adherence to regulatory and ethical standards set by SASW and internal policies.

Interdisciplinary Teamwork

Collaborate with nursing, therapy, and medical staff to ensure integrated, person-centered care.

Participate in care plan meetings, family conferences, and case discussions.

Contribute insights to improve residents’ psychosocial well-being and satisfaction.

Ad-hoc Duties

Support home-wide initiatives, events, or community outreach as assigned by the DON or management.

Provide assistance during audits, surveys, and strategic planning activities.