1 year Contract as per Ministry of Health Funding

Description

The successful incumbent 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 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 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 

Essential Duties and Responsibilities 

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 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: 

• 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  

• 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 province-wide monitoring, evaluation and reporting  

• In collaboration with the Alzheimer Society of Ontario and Ontario Heath, 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 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 with the development and maintenance of policies, procedures and resources to support First Link referrals, intake, system navigation, care coordination, and follow-up activities 

• Participate in knowledge transfer and exchange and collaborate with Alzheimer Societies across Ontario to support the delivery of best practices and ongoing quality improvement

Job Qualifications 

Education:  

• Diploma or Degree in nursing, social work, gerontology or other related health care discipline. Registered professional designation is preferred 

Experience:  

• 1 to 3 years client service experience in the health and/or social service sectors  

• Experience working directly with people living with Alzheimer’s disease or other dementias and their care partners 

• Experience and knowledge in management of chronic and complex health conditions  

• Knowledge of available community services/supports and clinical, social and residential care options 

• Understanding of roles and linkages across primary care, community care and specialized geriatric services  

• Strong knowledge of client-centred philosophy 

• Knowledge of clinical practices and training models related to dementia (e.g.: P.I.E.C.E.S. and U-First!) 

• Experience in assessment and care planning/coordination  

• Experience working in settings requiring inter-professional collaboration 

Other Knowledge, Skills, Abilities or Certifications:  

• Excellent communication (verbal and written)  

• Exceptional interpersonal skills, including shared decision-making and facilitation

• Ability to prioritize workload and manage competing tasks  

• Ability to take initiative and be resourceful  

• Excellent problem-solving and change management skills  

• Proficiency in technology (e.g.: Microsoft office and case management and care coordination systems)  

• Demonstrated ability to work independently and within a team 

• Expertise and experience in cultural sensitivity and diversity  

• Ability to speak French is a requirement 

Travel Requirements:  

• Some travel in the district is required

Physical Demands:

• No special physical demands are required beyond the performance of general office duties 

• Significant periods sitting at the computer, but with the opportunity to move away from the work station 

• Sensory attention is required for the majority of the work day (looking at computer screen, reading documents, etc.) 

Start Date: As Soon As Possible

Please submit your resume and cover letter to: Tracy Koskamp-Bergeron, Executive Director via email to [email protected].

Please include ‘FLCN-Contract' in the subject line. 

We thank all who apply, but only those selected for an interview will be contacted. 

Commitment to Equitable Recruitment 

The Alzheimer Society of Ontario recognizes the value and dignity of each individual and ensures everyone has genuine, open, and unhindered access to employment opportunities, free from any barriers, systemic or otherwise. We are dedicated to building a diverse and inclusive work environment, where the rights of all individuals and groups are protected and all members feel safe, respected, empowered, and valued for their contributions.   

Our values include justice and connection and are the guideposts we use for decision-making of all kinds. We believe that this will guide the organization toward a place of inclusion for all - where equity and access to essential supports and services becomes the reality.  

We are committed to inclusive, barrier-free recruitment and selection processes in accordance with the Human Rights Code and AODA. The Alzheimer Society of Ontario welcomes those who have demonstrated a commitment to upholding the values of equity and social justice and we encourage applications from First Nations, Inuit and Métis, Indigenous Peoples of North America, Black and persons of colour, persons with disabilities, people living with dementia, care partners and those who identify as LGBTQ2S+.