Grant: Team Grant: Community-Based Primary Healthcare - LOI

Alzheimer's disease and related disorders (ADR) is a major concern for Canadian governments, clinicians and the population due to an increasingly vast number of people affected, particularly older people with multiple chronic diseases, and to the extensive impact on patients, families and society. There is a longstanding Canadian consensus that detection, diagnosis, treatment and care of patients with ADR should be mainly the responsibility of primary health care (PHC). However, ADR is still mostly managed by specialists, resulting in reduced access (waiting list) and increased fragmentation. There is a critical need to improve PHC for vulnerable persons with ADR. Their age and the presence of other chronic diseases require complex coordination across multiple care providers. Simultaneous health policy directions and local initiatives in Quebec (Qc) and Ontario (ON) have led to the introduction of an innovative collaborative care model (collCM) in PHC. This provides patient-centered care to address complex health problems, ensure continuous interdisciplinary care, and coordination among health and social services, patients and family caregivers. Both provincial health ministries have expressed the need to evaluate and refine the collCM before large scale introduction. We propose a formal evaluation to understand change and improvement; evolution of critical processes; and impact of the model on patient health and the health system. Our participatory research approach connects patients-caregivers, healthcare decision makers, managers, and clinicians to ensure a PHC system that is responsive to the needs of seniors. It will be achieved through a Joint Qc and ON Partners Council, a Canadian Partners Council and an International Advisory Committee. The collCM impact is expected to be broad, with notable improvement in patient access to services, quality and continuity of care, patient and caregiver satisfaction, and efficiency of the healthcare delivery system.