First Link Care Navigator-social Worker

**Alzheimer Society of Toronto**

The Alzheimer Society’svision is a world without Alzheimer’s disease and other dementias. Our mission is to alleviate the personal and social consequences of Alzheimer’s disease and related dementias and to promote research.

Our Values: Collaboration Accountability Respect Excellence

**First Link Care Navigator-Social Worker**

The First Link Care Navigator-Social Worker will coordinate and integrate supports and services around the person living with dementia and their care partner. In this direct client service role, they will be the key “go-to” person for families after a dementia diagnosis, with responsibility for identifying needs, supporting self-management goals, and strengthening the communication and care planning linkages between providers and across sectors along the continuum of care.

The First Link Care Navigator-Social Worker will strive to ensure that every person diagnosed with dementia and their care partners have timely access to information, learning opportunities and support when and where they need it in order to achieve the following outcomes:

- increase system capacity to provide families facing a dementia diagnosis with system navigation support
- improved client experience and health for the person living with dementia and their care partner(s)
- greater care partner capacity and competency to effectively manage their role and reduce incidence of crisis situations
- enhanced capacity for the person living with dementia to remain in their own home and community for as long as possible

What You’ll Be Doing

**Navigation, Care Coordination and Counselling**:

- Support clients in navigating the system to access appropriate learning opportunities, support services, care and resources as identified in their individualized plan of service
- Pro-actively facilitate linkages, communication, information exchange and coordination between clients and service providers along the continuum of care
- Facilitate regular and ongoing care conferences between clients/care partners and all members of client/care partner care team. This may include in-person meetings and use of a range of technology options and/or accommodations, including language translation services, virtual supports, etc.
- Provide individual, goal-based, solution focused, dementia specific counselling to clients for whom the Single-Session counselling model does not meet their needs
- Provide Support Groups facilitation to various client cohorts as needed
- Leverage and maintain positive working relationships with physicians, health care professionals, health and community support service providers (e.g. hospitals, primary care, mental health, BSO, long-term care, retirement homes, police/EMS, specialized geriatrics, community Health Links), and other relevant partners through proactive outreach activities

**Initial Contact, Assessment and Care Planning**:

- Pro-actively manage incoming First Link referrals to facilitate early intervention and ensure that clients (people living with dementia and their care partners) have a named point of contact for care navigation support as early as possible before and/or after diagnosis
- 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

**Pro-active Follow-Up**:

- Monitor and provide proactive follow-up for clients and care partners to ensure ongoing collaboration across services/providers and to identify opportunities for new or emerging care options to meet changing needs and to address service/support gaps
- Provide supports to clients and care partners as they transition through use of different parts of the health, social and residential care systems

**Monitoring/Evaluation**:

- Collect, maintain and report required quantitative and qualitative data to support province-wide monitoring, evaluation and reporting
- In collaboration with the Alzheimer Society of Ontario and Ontario Health, participate in planning and implementation of evaluation to examine the overall effectiveness of First Link referral, intake, navigation, care coordination, and proactive follow-up functions, to ensure a timely response to emerging needs

**Service Delivery Standards and Quality Improvement**:

- Maintain confidential, accurate and current client records, including complete and thorough documentation for each client contact, in compliance with relevant privacy legislation and in accordance with professional standards and internal policies
- Ensure that client consents, privacy, and confidentiality are maintained in compliance with legislation, professional standards/regulations and inte