Aftercare Case Management Officer

STATEMENT OF PURPOSE

The Aftercare Case Manager will support the KTPH PsyMed team by providing comprehensive support and guidance to clients with psychiatric disorders during their transition from hospital setting to community-based services.

• Practicing case management in line with the established inclusion/exclusion criteria.
• Co-developing clinical pathways, workflows, escalation protocols, and patient stratification with input from multidisciplinary teams.
• Applying clinical expertise and resource knowledge to identify and refer patients to appropriate support services.
• Ensuring effective information flow among stakeholders, serving as a point of contact between KTPH and community partners.
• Facilitating regular case discussions with stakeholders to co-create solutions with the aim of achieving optimal patient outcomes.

Case Management

• Screen and identify suitable patients for enrollment into the Aftercare program based on established criteria.
• Collaborate closely with patients to assess needs and preferences for aftercare, ensuring active involvement in care planning.
• Provide psychoeducation and support to patients and families regarding treatment options and community resources.
• Serve as a point of contact for consulting physicians regarding patient concerns or updates.
• Review care plans (including medication management and therapy referrals) to ensure transitional support. Monitor follow-up appointments to ensure continuity of care and address barriers to attendance, if any.
• Cultivate strong partnerships among stakeholders and harness their collective resources and expertise to address patients’ complex needs and facilitate comprehensive support services for transitioning patients.
• Guide patients’ seamless reintegration into the community by coordinating tailored care plans and facilitating access to stability and recovery services.
• Foster proactive collaboration with multidisciplinary teams and stakeholders to ensure effective patient care across healthcare settings, promoting long-term recovery and well-being.
• Conduct home visits and interact with patients’ family members/caregivers when needed.
• Empower patients to manage their mental health effectively and make informed decisions about their care.
• Participate in discussions and case conferences with community partners to share knowledge and best practices.

Data Management and Administrative Duties

• Maintain accurate and confidential records of assessments and screenings for patients in electronic health record systems (EPIC), ensuring completeness and compliance with privacy regulations.
• Utilize data management tools to analyze trends and patterns in patient outcomes and program effectiveness.
• Generate reports to communicate findings and guide quality improvement initiatives.
• Conduct regular audits to ensure data integrity and compliance with regulatory standards.
• Oversee intake and assignment of referrals from hospital clinicians to the Aftercare program.
• Coordinate with community partners to streamline the referral process and ensure smooth transitions for patients.
• Schedule and organize meetings, conferences, and case discussions.
• Ensure timely communication and collaboration among participants.

JOB REQUIREMENTS

• Knowledge – Mental Health, Behavior science, suicide assessment and intervention, case management principles, familiarity with professional and technical emerging knowledge, community resources and governmental policies that impact the patients and basic counselling techniques.

1. Skills – good interpersonal communication, advocacy, problem solving and administrative duties.
2. Communication skills: to be able to communicate effectively and listen actively. Case managers must also be aware of nonverbal communication cues and be able to read nonverbal cues with patients.
3. Interviewing skills: to be able to evaluate the patients’ needs. Case managers need to be able to formulate questions, record client information and answer patients or family members’ questions promptly.
4. Teaching skills: to be able to help patients develop skills and knowledge to improve their life situation. Case managers need to help patients develop social skills, regain independence, identify and build coping strategies etc.
5. Advocacy Skills: case managers have to engage in advocacy on behalf of their patient. Case managers may attempt to resolve conflicts between patients and services providers and work towards protecting the best interests of the patients.
6. Organisational skills: Case managers have to be adept at planning and organisation to ensure service delivery to their patients in a timely manner.
7. Aptitude for teamwork and ability to work well with diverse groups, from other professionals to patients’ family members. Case managers don’t work alone to help their patients improve their quality of life. Instead they help patient achieve their goals as part of a much larger team.

Personal characteristics

1. Desire to help others: case managers must have a strong desire to help others or the negative aspects of the job can quickly lead to burnout.
2. Patience – case managers have to deal with a lot of red tape in the course of programs/ service implementation and in supporting patients.
3. Empathy: to be able to identify with the struggles patients are having.

Education and Experience

• Degree or equivalent experience – Degree in Psychology, Counselling, or NursingYears of Experience: 3-4 years in a mental health, either in community or healthcare environment.