To access care needs, provide care coordination, monitor the clinical and well-being of patients and their caregivers to ensure coping of the patients and a smooth transition of care to the community.

• Assess patient's medical, physical, cognitive, economic and social needs as well as their available support systems.
• Provide ongoing support and education to the caregivers, patients and families.
• Conduct post discharge follow-up via phone calls and/or home visits to ensure adequate and ongoing support and education to the patients, caregivers and families.
• Work in partnership with care professionals in the social and healthcare sectors to enhance patient's well-being across the continuum.
• Collaboration with patients, caregivers and the families to facilitate shared decision making.
• Participate in activities that contribute towards the improvement of the quality of patient c...