Conduct psychosocial assessments to identify patient’s needs, strengths and challenges in their home and in the community.
Collaborate with patients, families and relevant organisations to develop and implement individualized care plans that facilitate the transition from healthcare facility to home.
Actively participate in multi‑disciplinary team meetings to discuss and coordinate patients’ care.
Organise and participate in case conferences with relevant organizations and community agencies to enhance patient care and service coordination.
Provide emotional support and counselling services to patients and their families, addressing concerns and fostering resilience.
Conduct group sessions for patients or caregivers to provide shared learning and support.
Assist patients and their families in accessing available community services and support to meet their needs.