Job Title: Nurse Counsellor
Responsibility:
· Provide Nurse Counselling to United Primary Care Network (PCN) patients which includes education on Chronic Disease Management, Smoking Cessation, Mental Health, and health promotion.
· Conduct Diabetic Foot Screening, Foot Care education and Diabetic Eye Screening.
· Escalate cases to the doctors based on PCN escalation protocol. Raise “priority risk” cases for case discussion with the doctors.
· Educate patients on the use of medical devices such as blood pressure monitors, blood glucometers, inhalers.
· Track, document and review patient’s progress in chronic disease management and lifestyle changes. This can involve telephone consultations and telehealth monitoring.
· Identify patients with poorly controlled clinical indicators for closer management and monitoring. Work with individual patients to develop or tailor individual health plans and to revise and change health plans according to needs. Deliver direct patient care as needed according to established standards and protocols.
· Work closely with the Primary Care Coordinators (PCCs) in care coordination and care transition. This will involve liaising with the Public Institutions, Clinic Doctors and Clinic Assistants, Community Health, and Social Providers.
· Provide inputs on clinical results to the various clinics in the network.
· Review or revise nursing guidelines, standards and procedures related to Chronic Disease Management.
· Comply with universal precautions and adhere to all infection control practices in the delivery of nursing care.
· Always maintain confidentiality of patient medical records.
· Participate in continuing nursing education to maintain currency of practice and contribute to PCN quality improvement to enhance care standards and patient outcomes.
· Perform any other adhoc duties assigned by the Head of PCN.
Job requirements:
· Registered nurse with the Singapore Nursing Board.
· Currently practicing as a nurse or case manager.
· At least 5 years of clinical nursing experience as a staff nurse in hospital and/or primary care.
· Advanced Diploma in Nursing with specialisation in Chronic Disease management.
· Able to travel around from clinic to clinic.
· Nurses dealing with dialysis as chronic disease will also be considered.
