Job Description
Social Worker (Journey-Based Care)
Req ID:  1114
Posting Start Date:  23/09/2026

About Us

NTUC Health Co-operative Limited (NTUC Health) is an NTUC enterprise that provides a comprehensive and integrated suite of quality and accessible health and eldercare services to meet the growing needs of families and their dependents. Building on close to three decades of experience and expertise, NTUC Health is among the largest providers of active ageing, senior day care, nursing home, and home personal care services in Singapore. We also serve vulnerable seniors in selected areas in Singapore through Community Case Management Services (CCMS), CREST mental health support, and a sheltered senior group home. In addition, we run a family medicine clinic.

Our purpose is to achieve ‘health for life’; enabling healthy and fulfilling years by being a trusted partner of seniors and their families in our community.

For more information, please visit ntuchealth.sg or follow us on Facebook, Instagram, and LinkedIn.

Services:  Senior Day Care | Home Care | Nursing Home | Active Ageing and Senior Fitness | Rehabilitation and Physiotherapy | Family Medicine

Community Support: CCMS (Community Case Management Services) | CREST (Community Resource, Engagement and Support Team) | Henderson Home

Job Description

Job Role Summary: 

We are hiring Social Workers across our Active Ageing Centre (AAC), Senior Day Care (SDC) and Home Care services. 

The Social Worker provides psychosocial assessment, counselling, caregiver support, care coordination and resource mobilisation for seniors and their caregivers across Active Ageing Centre (AAC), Senior Day Care (SDC) and Home Care services.

Guided by Journey-Based Care, the Esther Care Philosophy and person-centred practice, the Social Worker partners with seniors, caregivers, multidisciplinary teams and community partners to understand “What Matters Most” and develop integrated care plans that promote wellbeing, independence, caregiver resilience and ageing in place.

Each service area offers a different social work focus and practice setting. Depending on the service, opportunities may involve prevention and community development, complex case management and psychosocial intervention, or home-based care and caregiver support. 

 

You will need to:

1. Journey-Based Care, Person-Centred Assessment & Care Planning

  • Champion and apply Journey-Based Care and the Esther Care Philosophy in daily practice.

  • Engage seniors and caregivers using "What Matters Most" conversations to understand their goals, preferences and priorities.

  • Conduct appropriate psychosocial, caregiver, functional and financial assessments to identify needs, risks and available resources.

  • Develop, implement and review integrated One Care Plans in collaboration with seniors, caregivers and multidisciplinary teams.

  • Apply person-centred, strengths-based and holistic approaches to support seniors and caregivers across their care journey.

  • Facilitate appropriate referrals and linkages to internal and external health and social care service

 

2. Psychosocial Assessment, Counselling & Intervention

  • Provide psychosocial assessment, counselling, emotional support, crisis intervention and appropriate social work interventions.

  • Support seniors and caregivers experiencing adjustment difficulties, grief and loss, social isolation, family conflict, caregiver stress, mental health concerns and dementia-related challenges.

  • Provide psychoeducation and interventions to strengthen coping, resilience, self-efficacy and informed decision-making.

  • Identify individuals requiring specialist intervention and facilitate timely referrals.

  • Monitor psychosocial needs and review interventions in response to changes in circumstances.

 

3. Caregiver Assessment & Support

  • Assess caregiver burden, resilience and support needs.

  • Develop caregiver support plans and provide counselling and psychoeducation.

  • Facilitate access to respite services, caregiver training and community resources.

  • Strengthen caregiver capacity and resilience to sustain caregiving safely.

  • Organise and lead peer support group for caregivers, giving them a safe place to learn from each other experiences.

  • Reach out to the public by giving talks about caregiver support services.

Job Description (Continued)

4. Financial Assessment, Resource Mobilisation & Advocacy

  • Conduct financial assessments and identify financial barriers affecting access to care and support.

  • Assess eligibility and facilitate applications for relevant government assistance schemes, subsidies, grants and financial assistance programmes.

  • Mobilise internal and external resources to address healthcare, psychosocial, financial and practical needs.

  • Support seniors and caregivers in navigating Singapore's health and social care system.

  • Advocate for seniors and caregivers to promote timely and equitable access to appropriate services and resources.

5. Care Coordination & Care Transitions

  • Coordinate care and services across internal service areas, healthcare providers, community organisations and relevant agencies.

  • Participate in multidisciplinary case conferences and care planning meetings where appropriate.

  • Facilitate care transitions following hospital admission, discharge, deterioration in health or changes in care arrangements.

  • Monitor client and caregiver outcomes and review care plans in response to changing needs.

  • Promote continuity of care across the senior's and caregiver's journey.

 

6. Mental Health, Dementia & Safeguarding

  • Identify psychosocial, mental health, dementia, behavioural and caregiver-related concerns.

  • Screen for concerns such as depression, anxiety, cognitive decline, social isolation and caregiver burnout where appropriate.

  • Identify risks relating to abuse, neglect, self-neglect, family violence and caregiver breakdown.

  • Develop safety and risk-management plans in collaboration with the multidisciplinary team and relevant agencies.

  • Coordinate timely referrals and interventions with appropriate specialist, statutory and community services.

 

7. Multidisciplinary Collaboration & Capability Building

  • Collaborate with doctors, nurses, therapists, psychologists, care managers, Well-being Coordinators, care staff and community partners to provide holistic, integrated care.

  • Provide psychosocial consultation and professional guidance to multidisciplinary colleagues.

  • Contribute to multidisciplinary assessment, case discussions and integrated care planning.

  • Support capability building in Journey-Based Care, person-centred practice, psychosocial care, mental health awareness, dementia care and caregiver engagement.

  • Contribute to staff education and training initiatives where appropriate.

8. Documentation, Quality Improvement & Service Development

  • Maintain timely, accurate and professional documentation, assessments, case notes, care plans and reports.

  • Monitor client, caregiver and service outcomes and contribute to relevant quality indicators.

  • Participate in quality improvement, research, innovation and service development initiatives.

  • Contribute to the development and evaluation of integrated care pathways and service models.

  • Support the use of digital solutions and AI-enabled documentation, where applicable, to enhance productivity, documentation quality and integrated care deliver

Qualification

You should possess:

  • Degree or Postgraduate Degree in Social Work recognised by the Singapore Association of Social Workers (SASW).

  • Registered Social Worker (RSW) preferred or eligible for registration.

  • Minimum 2–5 years of experience in community care, eldercare, medical social work, home care or social service settings.

  • Experience working with frail older adults and caregivers is preferred.

  • Knowledge of Singapore's community care ecosystem, financial assistance schemes and long-term care services.

  • Experience in complex case management, multidisciplinary practice, caregiver support or community-based practice is an advantage.

  • Experience in community development, outreach, group work, community engagement or preventive services is an advantage.

  • Experience in multidisciplinary care coordination is an advantage.

Other Information