The Alzheimer Society of Toronto’s vision is a world without Alzheimer’s disease and other dementias. Our mission is to alleviate the personal and social consequences of Alzheimer’s disease and related dementias and to promote research.

Our Values: Collaboration Accountability Respect Excellence

Position Title: First Link Care Navigator / Social Worker (12-Month Contract) - 35 hours per week

Reports to: Manager, Clinical Programs

Role Overview 

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

The ideal candidate will have 3-5 years’ relevant work experience, especially client service experience in the health and/or social service sectors working directly with people living with Alzheimer’s disease or other dementias and their care partners. 

Work location: Main office at 20 Eglinton West, 16th Floor.

Key Responsibilities - What You’ll Be Doing:

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 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-centered approach
• Identify needs related to care coordination across service providers and outline responsibilities of all parties

Navigation, Care Coordination and Counselling 

• 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

Proactive Follow-Up / Monitoring & Evaluation

• 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

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 

Expectations - What You Bring

Education and Experience

• 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

Other Knowledge, Skills, Abilities or Certifications

• As English is the primary working language at the Alzheimer Society, exceptional written and verbal communication skills is required
• 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 (e.g.: 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 
• 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 

Employment Conditions

• Work status: Must be legally entitled to work in Canada. Experience gained in Canada or internationally is valued.
• Travel requirements: Occasional travel may be required.
• Physical demands: Significant periods sitting at the computer, but with the opportunity to move away from the workstation. Sensory attention is required for the majority of the workday (looking at computer screen, reading documents, etc.)

Total Compensation / What We Offer

• Hiring salary range: $62,000 - $68,000.
• Paid time off: Paid Vacation (15 days), sick leave (18 days), personal days (2) & Equity Floater days (3) per fiscal year (prorated from start date)
• Work arrangement: Hybrid Work; working from home, choice of offices and flexible hours, minimum of 1 day per week.  

Commitment to Equitable Recruitment

The Alzheimer Society of Toronto 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. Accommodation is available on request for candidates taking part in all aspects of the selection process, in accordance with the Human Rights Code and AODA.

The Alzheimer Society of Toronto 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 2SLGBTQIA+.

• Our organization does not use AI tools to screen or evaluate resumes. All applications are reviewed directly by members of our hiring team.
• We thank everyone for their expressed interest – and are truly appreciative of the time individuals put into applying – but with the limitations of time, only those selected for an interview will be contacted. 
• All application materials will be retained for a minimum of three years after access to the posting by the public is removed.