Dementia Care Navigator
Position Summary
The Dementia Care Navigator is responsible for supporting patients and families throughout the course of a dementia diagnosis. Working collaboratively with physicians and advanced practice providers (APP), the Dementia Navigator helps coordinate medical, behavioral, and social services while providing education, counseling, and resource navigation for patients and caregivers and is critically responsible for ensuring impactful, high quality, meaningful outcomes and associated caregiver satisfaction and is the focal liaison for the Cognitive Care Center and the greater, global community.
This role focuses on improving patient outcomes, supporting caregivers, and helping families navigate the complex healthcare, community, and social service systems associated with dementia care.
The Dementia Navigator serves as a central point of contact for patients and caregivers, ensuring continuity of care and connecting families with appropriate community resources and support services.
Key Responsibilities
- Patient & Family Navigation
- Serve as the primary navigator for patients diagnosed with dementia and their caregivers.
- Provide education about dementia diagnoses, disease progression, treatment options, and expected care needs.
- Support families in understanding care plans developed by the physician and APP.
- Assist families in navigating healthcare systems, specialty services, and community resources and in the identification of any unmet social determinants of health as well as focal caregiver stressors.
- Provide emotional support and counseling to caregivers and family members.
- Care Coordination
- Work closely with the physician and APP to support coordinated dementia care.
- Assist in implementing individualized care plans and participate as needed in any case management follow-ups or post-visit outreach.
- Coordinate referrals to specialists, therapy services, home health, and community programs.
- Facilitate communication between the care team, patients, caregivers, and outside providers.
- Monitor patient and caregiver needs and identify emerging risks or barriers to care.
- Caregiver Support & Education
- Provide counseling and support to caregivers managing the emotional and practical challenges of dementia care.
- Educate caregivers on behavioral symptom management, safety strategies, and communication techniques.
- Facilitate caregiver support groups or educational sessions when appropriate.
- Connect families with local and national support resources.
- Community Resource Navigation
- Assist families in accessing community resources such as:
- Respite care
- Adult day programs
- Long-term care planning
- Transportation services
- Home safety assessments
- Legal and financial planning resources
- Coordinate referrals to programs offered by organizations such as the Alzheimer's Association and other community partners.
- Develop a local resource directory for families and assist in building community partnerships
- Safety & Crisis Intervention
- Assess risks related to dementia progression, including wandering, medication adherence, and caregiver burnout
- Adhere to departmental escalation protocols for when acute safety concerns are identified
- Assist families in developing safety plans and contingency care strategies.
- Provide crisis intervention and connect families with urgent support resources when needed.
- Documentation & Program Support
- Document all patient interactions and care coordination activities in the electronic health record (EHR).
- Track key metrics related to patient engagement, caregiver support, and resource utilization.
- Assist in developing program workflows and best practices for dementia care navigation.
- Participate in interdisciplinary team meetings and case conferences.
Qualifications
- Education
- Batchelor’s Degree in Social Work, or an equivalent degree in the social &/or behavioral sciences from an accredited program, or a nursing degree with associated licensure.
- Experience
- minimum of two years in behavioral health, &/or eldercare
Preferred
Experience working with geriatric populations.
Experience in dementia care, behavioral health, or care coordination.
Knowledge of community resources for older adults and caregivers.
- Skills & Competencies
- Strong knowledge of dementia and geriatric care needs
- Excellent communication and counseling skills
- Ability to support patients and families during emotionally challenging situations
- Care coordination and system navigation expertise
- Cultural sensitivity and patient-centered care approach
- Strong organizational and documentation skills
- Ability to collaborate within an interdisciplinary care team
