A 2019 report by the Canadian Academy of Health Sciences identified the importance of evidence-informed implementation strategies in reforming dementia care. Such implementation strategies may be relevant to changing clinical practice in the wake of Canada's impending federal dementia plan (initiated by Bill C-233). As this federal dementia plan is elaborated, there may be value in looking ahead to some of the implementation challenges likely to be faced "on the ground" in healthcare settings. We thus conducted a rapid review of provincial and national dementia plans from high-income countries and reviewed studies on implementation strategies to dementia care. We advance seven key implementation strategies that may be useful for future dementia care reform.
As the Canadian population ages, healthcare systems have become increasingly interested in exploring new ways to deliver services to frail older adults, and in particular older adults with dementia. The Specialized Seniors Clinics (SSCs) are an innovative integrated network of six outpatient clinics in BC's Fraser Health Authority that utilize interprofessional teams to provide comprehensive geriatric assessments and care planning for frail older adults. The SSCs provided approximately 19,000 appointments in the past fiscal year, and clients and primary care physicians are highly satisfied with the model. This article describes the SSC model and provides reflection on the model development, implementation and standardization processes.
BACKGROUND:Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario.METHODS:Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation.RESULTS:The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period.CONCLUSIONS:Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.
The Bridges to Care for Long-Term Care research project aimed to facilitate improvements in outcomes for long-term care residents through the provision of knowledge-to-practice and quality improvement resources by trained facilitators. Point-of-care staff reported improved communication and collaboration, improved use of scope of practice and implementation of best practice knowledge. Overall, participating long-term care homes demonstrated an enhanced capacity for common care issues of the elderly (pneumonia, falls, bacteriuria and behavioural and psychological symptoms of dementia) and the ability to effectively engage in quality improvement processes with efficient and effective use of healthcare resources.
As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the "state of the art" in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on "after-the-fact" curative care towards "before-the-fact" prevention and maintenance in the community. Drawing on results from a "balance of care" study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly "default" to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable "ground-up" change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, "closer to home."
Transitions between hospital and community are particularly challenging for vulnerable adults experiencing behavioural and psychological symptoms (BPSD) of dementia. Too often, miscommunication results in triggering a recurrence of disruptive behaviours leading to frustration of staff and families. As part of the implementation of Health Quality Ontario (HQO) Quality Standards, this project involved improving transitions using an electronic-based care plan on a 23-bed geriatric dementia unit in a mental health hospital. "My Dementia Careplan," is an interprofessional care plan that was developed in the electronic medical record (EMR) to enhance communication of information between healthcare providers when patients are being discharged to the community. It is written from the patient's perspective in collaboration with the family and interprofessional team. It describes strategies to manage behavioural challenges along with the standardized tools to objectively monitor progress. This care planning will help to support transition of knowledge between hospital and community.
In their paper, Morton-Chang et al. (2016) discuss how aging societies are struggling and trying to cope with the rapidly increasing numbers of persons living with dementia (PLWD). In that sense, the Canadian case is not unique. On the contrary, it is very similar to other developing countries. Therefore, it is worthwhile to reflect from another country's perspective on this unprecedented societal development. In this paper, I will consider the challenge of dealing with increasing numbers of PLWD from the European and, in particular, Dutch perspectives. Whereas, MortonChang et al. pose the question: "How do we get there from here?" I will address the issues of what the "there" should be and how we get there from my European/Dutch perspective. I will provide my view on how the roadmap can be drawn, who needs to be on the tour, who might be the guide and what conditions need to be in place to arrive at the desired destination.
In 2012, the World Health Organization estimated that the number of people living with dementia worldwide was approximately 35.6 million; they projected a doubling of this number by 2030, and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing providers is a common part of the dementia journey in most countries. Previously published research confirms that caring for people living with dementia in such facilities often creates moral distress for nursing care providers. In this paper, the authors share additional findings from a two-year, two-phase, mixed methods study of moral distress as experienced by nursing caregivers of residents with dementia in residential care settings in a Western Canadian province. The findings relate to strategies to reduce moral distress in this caregiving group, with a particular focus on the role of supportive and responsive leadership. Important implications for practice and for leadership in the residential care sector are presented.
An important theme emerging in health services policy is that an individual's health - or lack of - is often attributable to situations and circumstances far beyond his or her control. We now understand that low levels of education, unemployment, poverty and other socio-economic factors too often also equate with poor health and lower life expectancies. Policy makers seeking to address health inequities will need to look outside of the traditional boundaries of health services to arrive at solutions and strategies to address the issue.
An important theme emerging in health services policy is that an individual's health - or lack of - is often attributable to situations and circumstances far beyond his or her control. We now understand that low levels of education, unemployment, poverty and other socio-economic factors too often also equate with poor health and lower life expectancies. Policy makers seeking to address health inequities will need to look outside of the traditional boundaries of health services to arrive at solutions and strategies to address the issue.
Even as the number of people living with HIV (PLWH) is rapidly increasing in China, qualitative studies investigating the effect of HIV stigma on daily lives remain limited. The current study aims to fill this gap in research with attention to not only the experiences but also the coping strategies of PLWH in southwest China. We conducted 90 in-depth interviews in Guangxi, China. Our participants included both PLWH and individuals in their surrounding community (e.g., spouse, children, health workers). Our interview data showed an intense manifestation of HIV stigma in domestic spheres. Other close community members (e.g., relatives, friends, neighbours) also worked both to discriminate against PLWH and simultaneously thwart possible stigma by association. By explaining how stigma affects both PLWH and their family members, the current study seeks to help both citizens and health practitioners better understand the effects of stigma on PLWH, their friends and their families.
In India, though the prevalence of low birth weight (LBW) is estimated to be nearly 30%, routine reporting by the government consistently under-reports it as 12%, with resulting mismatched rectification efforts. We designed a programme comprising weight measurement standardization training, a pilot study-based sample size calculation, re-training and certification of personnel and finally a validation exercise. Paired birth weight readings of 404 newborns by a staff nurse and a research nurse were compared. LBW (<2,500 g) prevalence was 18% and 36% according to staff nurse and research nurse, respectively. Thus, it is feasible to set up simple validation exercises.
This study examined gender differences in the prevalence of heart disease in India in terms of type of care sought and biological risk factors. The analysis included 142,620 people aged 30 and above from the National Sample Survey Office's 71st round of 2014. While men and women have the same prevalence of seven per 1,000 persons, using a form of prevalence odds ratio the analysis indicated that women were likely to seek care at lower levels of service provision, even though they carried a higher level of multiple morbidities. This difference is not because of the survival effect of women living longer with heart diseases when compared to men. It is possible that women with heart disease complicated by multiple co-morbidities have limited treatment options. Nevertheless, these constraints are not entirely biological and therefore whether these are a consequence of gender discrimination in care options needs further examination.
Cleft lip and/or palate (CL/P) are the most prevalent craniofacial birth defects in humans, affecting around ten and a half million people across the world and over three hundred thousand in Brazil. Of that, about 70% of the cases occur as a nonsyndromic form, while the remaining 30% are syndromic. In turn, individuals with nonsyndromic CL/P (NSCL/P) often have anatomic deformities involving the lip, alveolar ridge and palate. In this case, the treatments generally require multiple surgeries and various other health interventions throughout childhood, adolescence and adulthood. Another relevant point is that various problems regarding the treatment of NSCL/P in Brazil through the Unified Health System (SUS) have been reported. There are also many inconsistencies in this scenario, including the territorial coverage of healthcare assistance from the craniofacial centres across the country. However, very little data can be found in the scientific literature about the current situation for the treatment of NSCL/P in Brazil. Thus, the present article discusses the existing consensus and legislation, the scope of the SUS, as well as inconsistencies and future perspectives related to the treatment of these craniofacial abnormalities at a national level.
Health workforce challenges remain a critical bottleneck in achieving universal health coverage (UHC) goals in most countries. As it stands, health professional training is primarily clinical, curricular and delinked from the needs of the health system. To achieve global health goals and maximize opportunities for employment and economic growth, all in the context of limited fiscal realities, a paradigm shift is needed with respect to the health workforce and corresponding education systems. There is a need to shift towards fair, gender friendly employment at a rate that matches the overall growth of the health economy, which acknowledges the role of the private sector in education and training. This paper emphasizes the importance and implications of such a paradigm shift. It argues the need for a 21st century framework for health professional education. This framework should represent a more satisfactory interface between supply and demand for health professional labor, in line with the need for UHC, job creation and economic growth.
The need for engaging citizens in healthcare policy making is critical, and different approaches are gaining traction internationally. However, citizen engagement seems more difficult to implement in low- and middle-income countries because of political, practical and cultural reasons. Despite this, countries such as India, Malawi, Tanzania, Ethiopia, Rwanda, Mozambique, Egypt have initiated community engagement initiatives, which are contextually unique, and can be used as examples to learn from for the future. Overall, community voices need to play a bigger role in forming policy; they hold the key to improve health and forward growth. Evidence needs to move out of communities and districts through broader communication and knowledge translation avenues to influence and shape national and global level policies and strategies.
Digital tools play an important role in supporting front-line health workers who deliver primary care. This paper explores the current state of efforts undertaken to move away from single-purpose applications of digital health towards integrated systems and solutions that align with national strategies. Through examples from health information systems, data and health worker training, this paper demonstrates how governments and stakeholders are working to integrate digital health services. We emphasize three factors as crucial for this integration: development and implementation of national digital health strategies; technical interoperability and collaborative approaches to ensure that digital health has an impact on the primary care level. Consolidation of technologies will enable an integrated, scaleable approach to the use of digital health to support health workers.PURPOSE:As this edition explores a paradigm shift towards harmonization in primary healthcare systems, this paper explores complementary efforts undertaken to move away from single-purpose applications of digital health towards integrated systems and solutions that align with national strategies. It describes a paradigm shift towards integrated and interoperable systems that respond to health workers' needs in training, data and health information; and calls for the consolidation and integration of digital health tools and approaches across health areas, functions and levels of the health system. It then considers the critical factors that must be in place to support this paradigm shift. This paper aims not only to describe steps taken to move from fractured pilots to effective systems, but to propose a new perspective focused on consolidation and collaboration guided by national digital health strategies.
Dr. Yansané is the senior policy advisor to the Minister of Health in Guinea and the former Head of the Minister's Office and former Secretary General, Health. He has been instrumental in advocating for and co-organizing the États Généraux de la Santé in Guinea in 2014. His perspective is clearly one of a policy and decision-maker who has a particular interest in bringing population views, needs and expertise into the policy-making process in the hope that it will lead to improved buy-in of the policy and better implementation. Dr. Yansané was requested to provide input on the utility value of population consultations in his country and the added value from his perspective of more international debate on deliberative democracy in the health sector.
Tunisia embarked on a process of population consultation in 2013, the first phase of which is often presented as an example, including in the paper in this issue by Rohrer, Rajan and Schmets (2017). The present commentary aims to provide an update on the development and challenges encountered in recent years and also explore their causes and possible ways to move ahead.
