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Let's Go Home First Link Navigator

2 weeks ago

Niagara Falls, Canada Alzheimer Society Niagara Region Full time

**Alzheimer Society of Niagara Region (ASNR)**

**Mission, Vision and Values**

The Alzheimer Society of Niagara Region’s mission is to advocate for and with people living with dementia and their care partners, and provide access to a diverse range of appropriate resources and supports.

Our vision is to create a community where individuals with dementia and their care partners are fully supported to maximize their quality of life and well
- being.

Our Values

**C*ollaboration**, A**ccountability**, R**espect**, E*xcellence

**Position Description**

**Title: LEGHO- First Link Care Navigator**

**Reporting To: Director of Education**

**Salary: $62,000-$67,000 One Year Renewable Contract**

**Hours of Work: 40 hours
- Monday -Friday -8:30 am - 4:30 pm**

**Some Evening and Weekend work may be required**

**Position Summary**

The Niagara LEGHO (Let’s Go Home) program has two streams, targeting two population segments within the larger population of seniors 65+ in Niagara. The first stream aims to reduce hospital admissions and Alternate Level Care (ALC) in people 65+ living with dementia, and the second stream strives to reduce Emergency Department (ED) visits (and repeat visits) in people 65+ presenting to the ED with Canadian Triage Accuity Scale (CTAS) level of 3-5 with non-acute/clinical diagnoses.

The Let’s Go Home First Link Care Navigator (LEGHOFLN) will work within the ED to coordinate and integrate supports and services for clients who present to the ED and are identified by the Hospital Discharge Planner and/or the Home and Community Care Support Service Hospital Case Worker to be eligible for the LEGHO bundle of services. The goal of the LEGHO program is to help to prevent non-acute hospital admissions of people living with dementia and/or seniors (65+) that have a CTAS of 3-5 with non-acute diagnosis related to social determinants of health

For clients identified with a CTAS of 3-5 with non-acute diagnosis related to social determinants of health the LEGHOFLN will directly refer to Community Support Services of Niagara Community Connector for facilitation of services.

For clients Living with Dementia the LEGHOFLN be the key “go-to” person for families referred to Program with responsibility of direct facilitation of the LEGHO bundle of services and for identifying needs, supporting self-management goals, and strengthening the communication and care planning linkages between Alzheimer Society of Niagara Region programs, other providers and across sectors along the continuum of care

Eligible clients will receive a minimum of three of the following for 4-6 weeks from the Basic LEGHO Bundle
- Meals
- Transportation
- Homemaking
- Wellness Checks
- Navigation

and/or the Additional Supports of:

- Friendly Visiting,
- Afterhours Support,
- Caregiver Support,
- Respite (Persons living with Dementia stream only)

**Duties and Responsibilities**

**Assessment and Care Planning**:

- Pro-actively oversee incoming LEGHOFLN referrals to facilitate early intervention and ensure that eligible clients have a named point of contact for LEGHO care navigation.
- Client 65+ with CTAS of 3-5 are referred to Community Support Services Community connector
- Clients living with dementia are supported by the LEGHOFLN
- Triage and coordinate LEGHOFLN referrals and link clients to LEGHO bundle of services.
- As required, gather information, conduct or review relevant assessments, and meet with clients (people living with dementia and care partners) to identify current and future needs, goals and level of risk.
- Establish appropriate intervention plans to meet bio/psycho/social needs using a person/family-centred approach
- Identify needs related to care coordination across service providers and outline responsibilities of all parties

**Navigation and Care Coordination**:

- Pro-actively facilitate linkages, communication, information exchange and coordination between clients and service providers by making referrals.
- Facilitate care conferences between clients/care partners and members of client/care partner care team, as necessary.
- In collaboration with internal and external parties, engage in problem solving and develop strategies to address/overcome barriers in effective coordination/integration of supports and services
- Leverage and maintain positive working relationships with physicians, health care professionals, health and community support service providers (e.g. hospitals discharge and HCCSS workers, primary care, memory clinics, mental health, BSO, long-term care, retirement homes, police/EMS, specialized geriatrics, community etc.), and other relevant partners through proactive outreach activities

**Pro-active Follow-Up**:

- Monitor and provide proactive follow-up for clients referred to the LEGHO program on a minimum of once per week during their 4-6 week period of service.
- Provide supports to people living with dementia and care partners as they transition through use of different