First Link Care Navigator, Dementia Resource Consultant

by Alzheimer Society Southwest Partners

Position Type: Full-time
Location: St Thomas, ON
Date Posted: Jan 03, 2025
Alzheimer Society Southwest Partners

Job Description

OrganizationAlzheimer Society Southwest Partners

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:                 
  • Alzheimer Society Southwest Partners: Elgin Site – 450 Sunset Drive, St. Thomas, (With some travel required within Middlesex, Oxford and Elgin counties).
  • St. Thomas, Elgin General Hospital (STEGH): 189 Elm St. St. Thomas

Summary:

This position is a full-time position working half as First Link Care Navigator (FLCN) - and half as Dementia Resource Consultant (DRC) - Elgin, with the DRC position being job shared with a colleague.

First Link Care Navigator:
The First Link Care Navigator (FLCN) 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 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 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.

Dementia Resource Consultant:  serving as the initial point of contact for St. Thomas Elgin General Hospital (STEGH) Emergency Department (ED) and Home and Community Care Support Services staff and people living with dementia and their care partners who enter STEGH ED.  These individuals may become clients of Alzheimer Society Southwest Partners (AlzSWP), including persons living with dementia and/or care partners.

Dementia Resource Consultants (DRCs) at AlzSWP work in the Emergency Departments as part of the Integrated Dementia Resource Team (DREAM Team). The DREAM team is a collaboration with 7 other regional Alzheimer Societies and respective emergency departments. The DRC 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 DRC follows their journey through service coordination and collaboration with other staff of AlzSWP and community partner organizations. The DRC also educates/models for the ED team members behavioural strategies to mitigate the risk or necessity for restraints in the ED through the use of Montessori activities and GPA strategies.


Duties and Responsibilities as FLCN:

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/fire/paramedics/community paramedicine, 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.

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.

Duties and Responsibilities as DRC:
  • Speaks with clients on the phone or in person (walk-in), acting as an initial point of contact for potential clients who present in the ED,
  • Screens and assesses potential care partner clients based on standard criteria for the services of the AlzSWP, specifically Counselling, BSO, and Respite,
  • Prioritizes assistance with ED patients who are expressing responsive behaviour and provides intervention activities when needed,
  • Educate, coach and role model for ED team members and staff on behavioural strategies through the use of Montessori and GPA techniques and tools to mitigate the risk or necessity for restraints,
  • 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 planning,
  • Liaises with other community agencies to facilitate referrals and coordinate client services as required,
  • Participates in coordinated care planning to ensure smooth transition out of ED back into the community as needed,
  • Liaise with primary care providers to support stabilization in the community of person living with dementia,
  • Gather statistical data as defined for this OHWest program.

Evaluation & Other Responsibilities
  • Annual performance review with Manager of Community Clinical Services,
  • Collect, maintain and report required quantitative and qualitative data to support region-wide monitoring, evaluation, and reporting to DREAM team,
  • In collaboration with the Alzheimer Society of Ontario and Ministry, 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,
  • Work with programs team to continually evaluate services by soliciting ongoing feedback from clients as well as completing written questionnaires as appropriate,
  • Always represent the AlzSWP in a professional manner, treating all internal and external clients with respect and dignity and always act in the best interest of the Society,
  • As an employee of a non-profit organization, you are expected to participate in fund development activities as required,
  • Other related duties as requested by the supervisor or Director of Programs and Services or CEO.

Requirements / Experience and Qualifications:
  • Minimum degree or diploma in social work, nursing or other related health care discipline,
  • 3 to 5 years client service experience in the health and/or social service sectors,
  • Registered (or eligibility for registration) with health professional designation such as the Ontario College of Social Workers and Social Service Workers (OCSWSSW) or Registered Nurses of Ontario (RNO),
  • Experience working with the over 65 age group,
  • Experience working with persons living with dementia and their care partners,
  • Hospital experience an asset,
  • Experience with populations that require behavioural support an asset,
  • Required to comply with hospital Occupational Health requirements,
  • Strong crisis management skills,
  • Strong assessment and case management skills required,
  • Experience facilitating education and/or support groups an asset,
  • Strong written and verbal communication skills,
  • Ability and knowledge to work within a computerized environment,
  • Ability to converse in a language other than English is an asset,
  • Valid driver’s license and access to own vehicle,
  • A Police Vulnerable Sector Check is required.

Preferred:
  • Degree in social work, nursing or other related health care discipline,
  • Minimum 5 years of experience providing care to people living with dementia,
  • Gentle Persuasive Approach (GPA), PIECES, ASSIST, and Non-Violent Crisis Intervention training


Working Conditions: 
Hybrid: office setting / hospital setting / some remote work from home. General office duties, typing, filing, occasional lifting / carrying 25lbs, reaching, bending, walking, sitting, and standing. Freedom of movement throughout the day. Some travel required.

About Us

Organization Overview:
The Alzheimer Society actively supports families and individuals affected by Alzheimer’s disease and other dementias. We advocate for and provide support services, education, and funding for research for those affected by Alzheimer’s disease and other dementias. 

Our Vision:
No one impacted by dementia goes unsupported.

Our Mission:
We provide community and person-centered support and education to those impacted by dementia.

Our Values:
Collaboration, Excellence, Respect, Compassion and Belonging.

Websitewww.alzswp.ca

TO APPLY:
Interested applicants will submit a complete application package including cover letter and resume in .pdf format to:  HR@alzswp.ca (with the job title listed in the subject line).

All applicants will be screened based on receiving a complete application package and according to the qualifications listed in the posting. We thank all applicants for their interest, only those selected for an interview will be contacted.

Commitment to Equitable Recruitment:
The Alzheimer Society Southwest Partners (AlzSWP) 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 (collaboration, excellence, respect, compassion and belonging) 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.  AlzSWP 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 2SLBGTQAI+.

Infection Prevention and Control & COVID-19 Considerations:
This position may require consistent wearing of proper PPE and completing education in proper Public Health guidelines surrounding PPE and Covid-19 protocols.