Care Navigator - Social Worker (12-Month Contract)

Alzheimer Society of Toronto•Toronto, ON

5d•Hybrid

About The Position

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 counselling 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 and counselling 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

Requirements

Minimum bachelor’s degree in social work, MSW preferred. Registration with OCSWSSW, in good standing, required.
Three (3) to Five (5) years’ relevant experience:
Working in the health and/or social service sectors, preferably managing chronic and complex health conditions and in settings requiring inter-professional collaboration
Providing individual, goal-based, solution-focused, dementia specific counselling to clients is required
Working directly with people living Alzheimer’s disease or other dementias and their care partners
Conducting assessments and care planning/coordination
Exceptional written and verbal communication skills is required
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

Nice To Haves

Bilingual or multilingual - effective verbal and written communication skills French or other languages is an asset
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 (eg: P.I.E.C.E.S. and U-First!)
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 changing management skills

Responsibilities

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 and counselling 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
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.
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 co-horts as needed
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
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 solution-focused, dementia specific counselling supports to clients and care partners as they transition through use of different parts of the health, social and residential care systems
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 at Home, 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
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