Annual Report 2017-2018

Looking ahead, getting ready

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6. An integrated care approach and interprofessionalism

Caring for people with dementia requires comprehensive and coordinated approaches, as well as a vast continuum of services. This continuum begins with prevention practices and obtaining a diagnosis in a context in which people are generally reticent about the idea of receiving such a diagnosis, and in which early diagnoses may influence the quality of life for them and their families.

That being the case, studies have pointed to the importance of close monitoring, following a diagnosis, in order to reduce the risk of social isolation and of creating uncertainty or increased stress.91

In short, for these types of disease, integrated care and a comprehensive approach are both desirable and essential:

[translation] Coordinated care is the outcome of collaboration between the person affected, that person‘s caregivers, health care providers and community service providers, in developing a plan to deliver appropriate care.92

It is therefore essential to establish multidisciplinary integrated teams on a regional basis in every LHIN.

Toronto’s regional geriatrics program, or the primary care-based memory clinics93 introduced in Ontario, recommend the creation of environments in which care is integrated. The memory clinics in particular are the best models because they can bring together interdisciplinary professional bilingual teams within a specific clinic to cover large areas (e.g., regional) while at the same time prioritizing Francophone patients. Hence each region could have its own bilingual memory clinic primarily for Francophone patients, like the model developed by Entity 4 and Reflet Salvéo.

Navigation services are also known to reduce inequities in accessing health services, particularly for vulnerable populations.94 These navigation services are essential for seniors in a minority linguistic context.95 Here again, there are existing models, such as the French Language System Navigation Services in the North Simcoe Muskoka region. These could be replicated for each LHIN in a designated region with provisions for a specific approach for seniors, with technological support and special training for navigators.

Given that most seniors want to remain in their community for as long as possible, homecare could easily become the preferred approach for people with dementia to end of life.96 If this approach is to be adopted, the Ministry of Health and Long-Term Care would nevertheless have to innovate, particularly in the use of technology and human resources, while providing a specifically Francophone navigation system for senior home care.


The Commissioner recommends that the Ministry of Seniors and Accessibility in partnership with the ministries of Health and Long-Term Care, Children, Community and Social Services, and the Office of francophone Affairs focus on measurable objectives to be achieved and concrete approaches to dealing with the aging of Ontario’s francophone population.

  1. Alzheimer’s Disease International. The global impact of dementia: an analysis of prevalence, incidence, cost and trends, in World. Alzheimer Report. London: International, ADI, 2015.
  2. Supra note 72.
  3. Lee, L. et al., Enhancing Dementia Care: A Primary Care-Based Memory Clinic. Journal of the American Geriatrics Society, 58 (11), 2010, p. 2197-2204.
  4. Feather Janice, Carter Nancy, Valaitis, Ruta, Kirkpatrick, Helen, «A narrative evaluation of a community-based nurse navigation role in an urban at-risk community». Journal of Advanced Nursing. 73 (12), 2017, p. 2997-3006.
  5. Carbonneau, C and Drolet, M, “La trajectoire des services sociaux et de santé d’aînés atteints d’une démence vivant en contexte francophone minoritaire : un engagement de multiples piliers durant une navigation complexe”, Reflets: Revue d’intervention sociale et communautaire, 20 (2), 2014, p. 220-233.
  6. Samus Quincy M. et al., “Home is where the future is: The BrightFocus Foundation consensus panel on dementia care Alzheimer’s & Dementia”, The Journal of the Alzheimer’s Association, 14 (1), 2018, p.104-114.

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