Community Dementia Navigator

Do you have a passion for working with older adults, including people living with Alzheimer’s disease and other dementias and their care partners? Are you looking for a position that offers variety and incredible job satisfaction?

**What We Offer**:

- Health benefits
- Pension plan
- Paid sick time
- Birthday off paid
- Generous vacation time
- Flexible work models
- Paid personal days
- Positive workplace culture

**About This Position**:
**Immediate Supervisor**:Manager of Community Clinical Services

**Direct Reports**:None

**Job Status**: Full-time, Permanent, 35 hours per week, occasional evening and weekend work required.

**Location**:

- London InterCommunity Health Centre (LIHC) - 659 Dundas Street, London
- Some occasional travel and work at Alzheimer Society Southwest Partners (AlzSWP) - 435 Windermere Road, London location

**Summary**:
The Community Dementia Navigator (CDN) 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 in providing supports for those with cognitive changes and 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 CDN will provide support connecting persons living with dementia and/or care partners to programs and services within the Alzheimer Society (such as, behavioural support outreach, counselling, respite) and other community resources. The CDN follows their journey through service coordination and collaboration with other staff of AlzSWP and community partner organizations. The CDN will also work closely with London Intercommunity Health Centre staff, collaborating to provide dementia specific support and resources to clients.

**Specific Job Responsibilities**:
**Initial Contact, Assessment and Care Planning**:

- Receive referrals from LIHC staff 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 with internal and external resource matching 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**:

- Working alongside LIHC staff, 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 and advocate for linkages, communication, information exchange and coordination between clients and service providers along the continuum of care,
- Participate in regular and ongoing care conferences between clients/care partners and all members of client/care partner care team as well as in coordinated care planning meetings with LIHC staff,
- 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. LIHC, hospitals, primary care, mental health, BSO, long-term care, retirement homes, police/fire/paramedics/community paramedicine, specialized geriatrics, community Health Links), and other relevant partners through proactive outreach activities,
- Participate in and support The Social, Memory Clinics or other programs where appropriate hosted by LIHC,
- Support awareness of First Link to health professionals, service providers and other relevant community stakeholders in collaboration with internal and external partners.

**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,
- Educate, coach and role model for LIHC team members and staff on behavioural strategies, dementia education and best practices as required,
- Provides families with relevant information for other community agencies and programs when appropriate, or if they require additional community services ex. legal counsel or financial planni