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