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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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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.


The needs of people living with dementia are dynamic and complex. Individualized management from providers of various disciplines with expertise in dementia care is necessary. An interprofessional team allows for the delivery of dementia care through a multifaceted and collaborative approach to meet the individualized needs and preferences of each person living with dementia and of their caregivers. The care team’s composition should be flexible and adapt to the person’s changing health, social circumstances, needs, and goals. People living with dementia and their caregivers are an integral part of the team and should participate in decisions about their own care.

For People Living With Dementia

You should have access to a health care team with expertise in dementia care. Your health care team may include doctors, nurses, a social worker, a pharmacist, an occupational therapist, recreational staff, personal support workers, and others.

You and your caregivers should be treated as important members of your health care team. This means your questions, concerns, observations, and goals are discussed and incorporated into your care plan, and you are supported to play an active role in your own care.


For Clinicians

Ensure that people living with dementia are cared for by an interprofessional team with expertise in dementia care. Involve people living with dementia and their caregivers in decisions about their own care.


For Health Services

Ensure that systems, procedures, and resources are in place for people living with dementia to receive care from an interprofessional team with expertise in dementia care.

Process Indicators

Percentage of people living with dementia in the community who receive community-based dementia care from an interprofessional team with expertise in dementia care

  • Denominator: number of people living with dementia in the community
  • Numerator: number of people in the denominator who receive community-based dementia care from an interprofessional team including at least one physician or nurse practitioner and at least one other health care provider, all with expertise in dementia care
  • Data source: local data collection

Percentage of people living with dementia who receive community-based dementia care from an interprofessional team with expertise in dementia care in which they and their caregivers are integral team members

  • Denominator: number of people living with dementia who receive community-based dementia care from an interprofessional team with expertise in dementia care
  • Numerator: number of people in the denominator and their caregivers who feel they are integral team members
  • Data source: local data collection
Interprofessional team

This includes at least one physician or nurse practitioner and one other regulated health care professional trained in dementia care. Other regulated and unregulated providers on the team may include family physicians, nurses, nurse practitioners, psychologists, occupational therapists, pharmacists, behavioural support workers, social workers, caregivers, administrative staff, personal support workers, speech-language pathologists, physiotherapists, geriatricians, neurologists, geriatric psychiatrists, dietitians, therapeutic recreation staff, and spiritual care staff.

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