First Link Care Navigator

**Alzheimer Society of Cornwall & District**

**The Alzheimer Society’s **vision 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**

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

**First Link Care Navigator**

The First Link Care Navigator 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 care partners, 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 will strive to ensure that every person living with dementia and their care partners have timely access to information, learning opportunities and support when and where they need it.

First Link Care Navigators report to the Program and Project Manager.

What You’ll Be Doing

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

- Pro-actively manage incoming First Link referrals within three (3) business days 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.
- Provide therapeutic support to the client either in a group or in individual sessions.

**Navigation and Coordination**:

- 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, video conferencing, etc.
- 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, 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.
- Support awareness of First Link to health professionals, service providers and other relevant community stakeholders in collaboration with internal and external partners.
- Participate in internal/external committees on an ad hoc basis.

**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 monitoring, evaluation and reporting.
- Participate in planning and implementation of evaluation to examine the overall effectiveness of First Link referral, intake, navigation, 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 internal policies.
- Maintain an advanced level of knowledge of Alzheimer’s disease and other dementias, including clinical manifestations, behaviours, current care practices, treatment options, placement options, available community resources, and all relevant legislation.
- Assist w