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

Our Values:

Collaboration Accountability Respect Excellence

Position Title:

Care Navigator-Social Worker (18-Month Contract) - 35 hours per week

Reports to:

Manager, Clinical Programs

The role of the Alzheimer Society of Toronto is to offer support, information, and education to people with dementia, their families, and their caregivers, to increase public awareness of dementia, to promote research, and to advocate for services that respect the dignity of the individual.

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

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

Navigation, Care Coordination and Counselling as required:

• 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

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 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

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 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 Alzheimers 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

There is a requirement to be in the office minimum 1-day a week.

Some occasional evening work may be required.

What You Bring:

Education:

• Minimum Bachelor degree in social work, MSW preferred.
• Registration with OCSWSSW, in good standing, required.

Experience:

• 3 to 5 years client service experience in the health and/or social service sectors
• Experience working directly with people living with Alzheimers 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 (eg: 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 and Attributes:

• 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

What We Offer:

Work life balance is important to us here at the Alzheimer Society. That is why we offer our employees:

• Paid Personal Days (2) & Equity Floater Days (3) per fiscal year, that can be used at any time
• 15 days (3 weeks) paid vacation per fiscal year.
• 18 paid sick days per fiscal year.
• Hybrid working arrangements: include working from home, choice of offices and flexible hours

Hiring Range & Salary Range:

Hiring Zone: $62,000 - $68,000

Commitment to Equitable Recruitment:

The Alzheimer Society 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. Accommodations are 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 welcomes those who have demonstrated a commitment to upholding the values of equity and we encourage applications from First Nations, Inuit and Mtis, 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+.

Closing Date: September 20th, 2025