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Alzheimer Society of Durham Region

First Link Care Navigator



Company Information

Alzheimer Society of Durham Region provides help for today by working with local and regional agencies to meet the needs of people with dementia. We also provide support and education programs for people with Alzheimer's disease and related dementia, and their family and professional care partners.

Job Description

First Link Care Navigator


Status:                  Full time – 35 hours/week


Reports to:         Manager of Family Support


Job Summary


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 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:

  • 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


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 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



  • 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, 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

Other Duties

  • Perform other duties consistent with the job classification, as required


Job Qualifications


  • Minimum Bachelor degree in social work, gerontology or other related health care discipline.  Registered health professional designation and Master’s level education preferred


  • Minimum 3 - 5 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 or other languages an asset


Travel Requirements

  • Must have insured vehicle and be able to travel throughout Durham Region


Physical Demands

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


Please submit your resume and cover letter to:

    • Please include the ‘Job Title’ in the subject line.

    • Salary range expectations should be included in your cover letter.

Closing Date:  Friday October 6th at 4 p.m.


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


The Alzheimer Society welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in all aspects of the selection process.

Contact Information

Alzheimer Society of Durham Region
Brian Joyce
Program Director
Posting Date: 22-Sep-2017Social Work Permanent, Full-Time Open 101-Nov-2017