• Lead home visits jointly with the Occupational Therapists (OT) during intake, conducting psychosocial assessments, identifying clients' community participation goals, and eliciting motivations to anchor the community reintegration journey.
• Collaborate with the OT to co-develop client-centered, goal-oriented care plans that align functional and psychosocial goals with the client's motivations.
• Conduct scheduled reviews to monitor progress on case management needs, reinforce goals in alignment with the client's motivations, and apply motivational interviewing to address barriers to behavioural change.
• Develop the Befriender Buddy volunteer scheme within assigned subregions (i.e. Hougang & Serangoon) - sourcing and recruiting volunteers from the community, onboarding them, co-facilitating training with the OT, and providing ongoing support to Befriender Buddies, in partnership with community stakeholders.
• Coordinate and assign tasks to ReAblement Care Associates (RCAs) delivering the intervention, and match each client with a Befriender Buddy.
• Introduce social prescription and begin linkage to community activities and groups of the client's choice, accompanying clients for their first visit where needed.
• Support client and caregiver understanding of the ReAblement process, providing stress and grief support to caregivers where needed, and addressing broader case management needs, motivations, and barriers to community reintegration, including facilitating home modifications and environmental adjustments.
• Support the formation and continuity of social and community groups, and continue linkage to these groups through to programme close-out.
• Support discharge planning towards the end of the programme, including helping clients fulfil their goals where achieved, and contribute to scheduling 6- and 12-month follow-up touchpoints.
• Facilitate interdisciplinary team meetings and case discussions with the OT, RCAs, and Befriending Buddies to ensure coordinated, whole-person care throughout the 12-week programme.
• Document assessments, progress notes, and discharge plans accurately and in a timely manner, including relevant case management and psychosocial records.
• Work closely with ICCP community partners — including AACs, home care providers, and social care providers — to ensure continuity of care beyond the programme.
• Support programme reporting and work closely with Home Therapy team to achieve programme outputs and outcomes.

Qualifications

• Degree in Social Work or a Graduate Diploma in Social Work.
• Minimum 2 years of relevant experience in Medical Social Work, preferably in community care, rehabilitation, or home-based intervention programmes.
• Demonstrated experience working within an interdisciplinary team (e.g. with OT), conducting client/family assessments, and coordinating care with community partners.
• Passionate in supporting clients' functional recovery, community reintegration, and caregiver/family well-being.