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Evidence to Improve Care

Dementia

Care for People Living in the Community

Click below to see a list of brief quality statements and scroll down for more information.


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment and Diagnosis
People suspected to have mild cognitive impairment or dementia receive a comprehensive assessment when signs are first identified. If diagnosed with either condition, they are then reassessed on a regular basis or when there is a significant change in their condition.

Quality Statement 2: Interprofessional Care Team
People living with dementia have access to community-based dementia care from an interprofessional team with expertise in dementia care, of which the person living with dementia and their caregivers are integral team members.

Quality Statement 3: Individualized Care Plan
People living with dementia have an individualized care plan that guides their care. The plan identifies their individual needs, those of their caregivers, and goals of care. The plan is reviewed and updated on a regular basis, including documentation of changing needs and goals and the person’s response to interventions.

Quality Statement 4: Named Point of Contact
People living with dementia and their caregivers have one or more named providers on the interprofessional care team who serve as a point of contact to facilitate care coordination and transitions across settings.

Quality Statement 5: Education and Training for People Living With Dementia and Their Caregivers
People living with dementia and their caregivers have access to education and training on dementia and available support services.

Quality Statement 6: Education and Training for Health Care Providers
Health care providers delivering care and services to people living with dementia receive education and training in dementia care.

Quality Statement 7: Access to Support Services
People living with dementia and their caregivers have access to support services that are individualized and meet their ongoing goals and needs.

Quality Statement 8: Caregiver Assessment and Support
Caregivers of people living with dementia are assessed on an ongoing basis and offered supports to address their individual needs.

Quality Statement 9: Safe Living Environment
People living with dementia have access to a safe living environment that meets their specific needs, including design modifications and a range of housing options.

Quality Statement 10: Access to Primary Care
People living with mild cognitive impairment or dementia have regular visits with a primary care physician or nurse practitioner who provides effective primary care that meets both their general health care needs and their specific needs related to cognitive impairment or dementia.

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Access to Primary Care

People living with mild cognitive impairment or dementia have regular visits with a primary care physician or nurse practitioner who provides effective primary care that meets both their general health care needs and their specific needs related to cognitive impairment or dementia.


Primary care plays a critical role in managing the complex health needs of people living with mild cognitive impairment or dementia. This care involves both their general health care needs and their needs related to cognitive impairment or dementia, as well as their caregivers’ health care needs.

More than 90% of community-dwelling seniors with dementia in Ontario have two or more coexisting chronic medical conditions, whose courses are often complicated by dementia. As dementia progresses, people experience challenges with memory, symptom awareness, decision-making, and expressive language, which can make it difficult for them to manage their general health and coexisting chronic conditions. It can be hard to adhere to medication regimens and to monitor themselves and perform the self-care required to effectively manage conditions such as diabetes, heart failure, and chronic obstructive pulmonary disease. Chronic conditions can become de-stabilized and exacerbated when a person has dementia, potentially resulting in visits to the emergency department, hospitalizations, deconditioning (muscle loss owing to inactivity) and earlier institutionalization.

To address these challenges, people living with dementia or mild cognitive impairment and their caregivers need timely access to primary care that:

  • Is person-centred (rather than disease-focused)
  • Is continuous and comprehensive for most health needs
  • Is coordinated and links to other health care professionals and resources across the health care system, as needed
  • Addresses individual needs and aligns with the person’s goals of care

Primary care also provides a critical link to specialist care and specialty programs, such as specialty dementia care and specialized geriatric services. To address complex medical and behavioural issues, functional complexity, and certain stages of illness, it is important for primary care clinicians to collaborate with, and get support from, specialists in dementia care, such as geriatricians, geriatric psychiatrists, and cognitive neurologists, as well with community support agencies.

For People Living With Mild Cognitive Impairment or Dementia

You should have a family physician or nurse practitioner who sees you regularly and knows your needs. This health care professional should monitor your health, provide care, and link you and your caregivers to other health care providers and support services that meet your changing needs and goals.


For Clinicians

Ensure that people living with dementia or mild cognitive impairment have access to a primary care provider to visit regularly. This individual provides person-centred, comprehensive, and coordinated care to meet their needs.


For Health Services

Ensure that people living with dementia have access to a primary care provider. Ensure the system can accommodate the provision of effective primary care to support the dynamic needs of those living with dementia.

Process Indicators

Percentage of people with mild cognitive impairment who have visited their primary care provider in the past 12 months

  • Denominator: number of people living with mild cognitive impairment
  • Numerator: number of people in the denominator who have visited their primary care provider in the past 12 months
  • Data sources: Ontario Health Insurance Plan (OHIP) Claims Database or local data collection

Percentage of people with dementia who have visited their primary care provider in the past 6 months

  • Denominator: number of people living with dementia
  • Numerator: number of people in the denominator who have visited their primary care provider in the past 6 months
  • Data sources: Ontario Health Insurance Plan (OHIP) claims database or local data collection
Regular visits

A person living with mild cognitive impairment should visit their primary care provider every 6 to 12 months, or sooner according to clinical need.

A person living with dementia should visit their primary care provider every 3 to 6 months, or sooner according to clinical need.

Effective primary care

Primary care is the person’s first contact with the health system. It is effective when it:

  • Is person-focused; rather than focusing on the disease or a single condition, it focuses on the whole person
  • Is accessible
  • Provides comprehensive care for most health needs (in collaboration with specialists, as needed)
  • Coordinates and integrates care and services when a referral to other health care professionals or home and community support services is required
  • Continues over time
  • Links to and gets support from specialists, as needed

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