Collaborative, Shared-Care Models

Recognizing the complexity of care, support and ongoing follow up that is required to support patients, caregivers living with and at risk for MCI and dementia, a collaborative shared- care approach with primary care and geriatrics is essential to provide a holistic approach to patients living well with MCI and dementia. An evidence based approach to case finding, access to appropriate and timely referrals for assessment, diagnosis and management, and awareness of community support services, provides persons living with dementia and their families with the knowledge and support they need throughout the dementia journey. Given the variety of primary care delivery models in the Champlain Region, three collaborative, shared-care models have been identified for our region.

The goals of implementing these models include: Early identification of seniors living with MCI or dementia or are at high risk for MCI or dementia. Timely access to cognitive assessment, diagnosis and best practice management focused on the primary care setting. Development of a collaborative, sustainable, shared care approach involving primary care, specialized geriatric services, CCAC, First Link and other community support services to support the care required to support the needs of patients and families living with cognitive impairment. Primary care physicians and teams who identify themselves as knowledgeable, skilled, and confident to identify, assess, and manage the care of a geriatric patient living with cognitive impairment.

For more information about any of the models outlined, or if you would like to discuss other opportunities for building capacity in your primary care practice, please contact RGPEO@toh.ca.

Centre for Family Medicine FHT Memory Clinic Model (Dr. Linda Lee Memory Clinic)

In an attempt to meet the needs of the patients, caregivers, and her colleagues at the Centre for Medicine Family Health Team, Dr. Linda Lee developed a primary care model that focused on early diagnostic assessment, treatment and follow up for those living with MCI and dementia. The model was designed to help her colleagues by addressing major barriers to optimal dementia care in primary care practice. The first Memory Clinic began seeing patients in 2006 and to-date 64 primary care memory clinics have been implemented in Ontario. In 2013 the Champlain LHIN led the way in committing to the implementation of 15 Memory Clinics in Family Health Teams and Community Health Centres throughout the region.

The aim of the clinic is to increase capacity within the primary care practice to assess and manage persons and their family members dealing with cognitive impairment. The memory clinic is run by family physicians and allied health care professionals who dedicate 1 to 2 days/month to work in memory clinics servicing their primary care practice patients. Each clinic is supported by a specialist for e-mail or telephone support.  This support helps to avert unnecessary referrals, improve the skills of the physicians and develops the specialist’s comfort with the skill level of the team.  The model builds capacity for care by increasing the ability of family practice to manage the majority of patients while appropriately referring the most complex of cases to specialists.

The following practices have developed memory clinics in their primary care practice for their patients.

  • Arnprior FHT
  • Clarence Rockland FHT
  • Connexion FHT
  • East Ottawa FHT
  • Family First FHT
  • Montfort Academic FHT
  • Ottawa Academic FHT
  • Southeast Ottawa CHC

Related Articles and Other Documents

  • Enhancing dementia care: A Primary care based memory clinic. Lee L, Hillier LM, Stolee P, Heckman G, Gagnon M, McAiney CA, Harvey D. Journal of the American Geriatric Society. 2010;58 (11): 2197-2204.
  • Building capacity for dementia care: A training program to develop Primary Care Memory Clinics. Lee L, Kasperski MJ, Weston WW. Canadian Family Physician. 2011; 57(7):e249-e252
  • Disclosing a diagnosis of dementia: Helping learners to break bad news. Lee L, Weston W. Canadian Family Physician. 2011; 57(7):851-852.
  • Cognitive enhancing drugs in dementia: Tips for the primary care physician. Lee L, Rojas-Fernandez C, Heckman G, Gagnon M. Canadian Geriatrics Society Journal of CME, 2011;1(1):5-9.
  • Developing memory clinics in primary care: An evidence-based interprofessional program of continuing professional development. Lee L, Weston W, Hillier L. Journal of Continuing Education in the Health Professions, 2013;33(1);24-32.
  • Lee L, Weston W, Heckman G, Gagnon M, Lee Joseph, & Sloka S. Structured approach to patients with memory difficulties in family practice. Canadian Family Physician, 2013:59;249-54.

MEMORY CLINIC MODEL (PDF)

Primary Care – Geriatric Assessment Clinic Model

The “Primary Care-Geriatric Assessment Clinic” model is founded on the integration of an experienced Geriatric Assessor working together with a primary care practice to support the assessment, diagnosis, and management of patients at risk for, or living with, undiagnosed cognitive impairment. The model involves a comprehensive geriatric assessment approach coupled with the use of standardized tools and best practices and is supported by case conferencing with a geriatrician.

To support local primary care group practices in addressing some of the identified barriers related to assessment, diagnosis and management of Mild Cognitive Impairment (MCI) and dementia the Geriatric Assessment Outreach Team has partnered with Family Health Organizations to pilot a shared care, in-house “Geriatric Assessment Clinic“ focused on cognition. In this model, an experienced Geriatric Assessor hosts a monthly clinic in the primary care setting, collaborating with the physicians and nurses in the primary care practice setting. The clinic supports the practice by completing a comprehensive geriatric assessment, and providing appropriate treatment and ongoing care management recommendations to the primary care physician and nurses. The model involves the use of standardized assessment tools and is supported by a geriatrician through case conferencing with the Geriatric Assessor.

An algorithm, developed for the pilot, outlines the flow as well as the commitments of the primary care practice and the geriatric assessor within the clinic. The “Geriatric Assessment Clinic” provides the primary care practice with increased capacity to offer geriatric assessments focused on cognition while supporting capacity building in the form of knowledge translation and system navigation of geriatric and community resources. To date, the model has been successfully implemented  in five primary care practices in the Ottawa Area.

Memory Care Program Model (Dr. Bill Dalziel)

This toolkit was creating to provide Health Care Professionals with a best practice model to implement a Memory Care Program in a Retirement home, Long Term Care home or Primary care setting. The toolkit is designed to provide the steps and resources required to ensure that persons can be properly screened and assessed for Mild Cognitive impairment or Dementia, supporting goals of earlier detection and potentially better outcomes for both person and family.

Toolkit (PDF)

Dementia Toolkit for Primary Care

To contribute to the vision outlined in the Integrated Model of Dementia Care: Champlain 2020 of “Being the best… for persons with dementia, their families, our health system and society,” the Regional Geriatric Program of Eastern Ontario has committed to support building capacity around dementia care. This includes the following:

Implementation of collaborative, shared-care models for early identification and management of  MCI and  dementia.
Access to online tools and resources. Page under construction.
Awareness of educational opportunities. Page under construction.

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