1. Family Care Managers:  A Community Based, Relationship Model of Care for Persons with Dementia and Their Care Partners
Marge Dempsey,
Alzheimer Society of Niagara Region,
St. Catharines, ON, Canada

2. Program goals
To develop a therapeutic relationship with and maintain/enhance the quality of life of individuals with dementia and their care partners.5,6
To provide/assist with access to information, education, support, and the necessary resources to enhance their quality of life in ways that are meaningful to them.5,6,8
To build a strong supportive community 4,5 in partnership with individuals with dementia, their care- partners, and other health care providers/ community agencies - shared care approach that ensures coordination of service and shared resources where appropriate.
To assist/enable individuals with dementia and their care-partners to navigate the existing support system
To create opportunities for strengthening formal and informal support networks through: experience sharing; information exchange; social interaction; and peer support.8,9,10
To provide a positive work environment of mutual respect where staff are: acknowledged, validated, supported and empowered

3. Partners in Care
Individuals do not experience dementia in isolation – many years from diagnosis to death
Many resources required as they move along the continuum of care
All encouraged to build on the strengths of the family
Clients
Adults of any age and ethno-cultural background who are experiencing symptoms of a progressive dementia of any kind
Their care-partners
Their families – including children 
Program serves over 1600 individuals with dementia and their care-partners/families/year
Family Care Managers
Cohesive Interdisciplinary team of health professionals (14)
nursing, social work, occupational therapy
Skills and expertise in the assessment, care and support of persons with dementia, care partners, families
Community Partners
Health professionals – medicine/psychiatry
Service providers – Personal Support/Respite/legal/financial
Care Facilities

4. Programs and Services Four Programs
First Link – Intake, triage and Community Liaison
Family Support – home visits, support groups, early stage programs
Intensive Case (most vulnerable) - psychiatric sequelae/behaviour
Support for those who live alone – potential risk
Developed over time an innovative community based, 2,3,4 relationship model 5,6 of care aligned with individual needs, beliefs,7 values and ethno-cultural diversity.
Advocacy is a major component
Response time is determined by priority of need
Holistic assessment
Client
Care partner - essential to the support of person with dementia
Other family members
Determine status of the individual/carepartner(s)/family
Develop Care Plan with the individual (to the extent of their capacity) carepartner(s)/family
Re-evaluated by all and revised as appropriate on each visit

5. Results The clients/families report :
improved quality of life as a result of the therapeutic relationship.
increased awareness of/access to the available resources
Over 80% of clients have at least one other community support in place e.g. day/respite program, personal support worker.
increased resilience as evidenced by an ability to cope more effectively with the day to day issues (repetitiveness, shadowing, etc.) as well as unexpected events.
improved relationships with the person with dementia.
strengthened formal and informal support networks
reduced isolation.
Staff surveys – staff job satisfaction is high 88% – we have had only 3 staff leave for another position in the 20 years of the programs operation - an average of one person every 7 years.

6. Conclusion
This innovative community based relationship model of family care navigation has evolved over time, based on the needs and gaps identified by persons with dementia and their care partners and families. The staff have been engaged in the role of care navigators - embracing a philosophy of relationship based care from the beginning - long before the terms were coined and the frameworks identified.
There has always been both qualitative (surveys/anecdotal) and quantitative (statistical data) evidence that the model was appropriate, effective and efficient. It is now clear, based on the current literature in all three areas, i.e. caregiver support and education,1-4 relationship based care,5,6 and care navigation,1,8-10 that our model incorporates a best practice approach for community support of persons with dementia and their care-partners/families. It embraces everything that not only maximizes the quality of life for all but also makes the journey along the continuum of care as supportive and seamless as possible.

7. References:
Rising Tide: The Impact of Dementia on Canadian Society. Alzheimer Society of Canada. 2010
GAUGLER J. E; ROTH L; HALEY W. E; MITTELMAN M. S. Can Counselling and support reduce burden and depressive symptoms in caregivers of people with Alzheimer's disease during the transition to institutionalization? Results from the New York University caregiver intervention study. Journal of the American Geriatric Society. 56(3):
VERNOOIJ-DASSEN M, JOLING K, VAN HOUT H, MITTELMAN MS. The process of family-centered counseling for caregivers of persons with dementia: barriers, facilitators and benefits. International Psychogeriatrics.  Aug; 22(5):
MITTELMAN MS,  HALEY WE, CLAY OJ, ROTH DL. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease NEUROLOGY 67:
KOLOROUTIS M. Relationship-Based Care: A Model for Transforming Practice  ed. Minneapolis, Minn: Creative Healthcare Management, Inc; 288 pages 2004.
WEYDT A. Mary's Story, Relationship-Based Care Delivery. Nursing Administration Quarterly. April/June - Volume 34 - Issue 2 :141–
NOWITZ L. Geriatric care management: spiritual challenges. Journal of Gerontological Social Work. 45(1-2):
LILLIS M, MACKIN K. The new navigators: Geriatric care managers forge paths for clients. Caring. 20(4):28-9. 2001
KELSEY SG, LADITKA SB. Evaluating the roles of professional geriatric care managers in maintaining the quality of life for older Americans. Journal of Gerontological Social Work.   52(3):  2009
Finkel SI. Dementia patients in primary care. Care managers offer a solution to providing ongoing care. Geriatrics. 58(8):42, 45. 2003