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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.

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.


It can be difficult and frustrating for people living with dementia and their caregivers to navigate the health system and know whom to contact when health issues or concerns arise. A point of contact on the interprofessional care team (see Quality Statement 2) makes communication easier and aids continuity of care and transitions across settings. This person should be an active team member who:

  • Closely coordinates with or is embedded within the person living with dementia’s primary care team
  • Is involved in the care of the person living with dementia and understands their current needs and care goals, as well as those of their caregiver
  • Is able to address the needs of the person living with dementia or connect the person with the most appropriate provider to address their needs

The point of contact on the interprofessional dementia care team is an essential component of person-centred dementia care.

For People Living With Dementia and Their Caregivers

Your health care team should provide you with the name and contact information for one or more team members who are coordinating your care on an ongoing basis.


For Clinicians

Ensure that people living with dementia and their caregivers have the name and contact information of one or more members of the care team responsible for coordinating their care and transferring information among providers.


For Health Services

Ensure that systems, processes, and resources are in place for care providers to serve as a point of contact for people living with dementia, their caregivers, and other providers involved in their care.

Process Indicator

Percentage of people living with dementia who have at least one named provider on their interprofessional care team who serves as their point of contact

  • Denominator: number of people living with dementia who receive care from an interprofessional care team
  • Numerator: number of people in the denominator who have at least one named provider on their interprofessional care team who serves as their point of contact
  • Data source: local data collection
Point of contact

The point of contact:

  • Is one or more named members of the interprofessional team
  • Supports communication and information sharing among health care professionals, community service providers, and the person living with dementia and their caregivers
  • Facilitates care coordination and transitions across care settings and providers

This person’s name and contact information is provided to the person living with dementia and their caregivers, and is included in the individualized care plan (see Quality Statement 3).

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