Plan de Atención del Alzahimer en Quebec

1. Quebec Alzheimer Plan
Implementation Policy Lessons
Howard Bergman MD, FCFP, FRCPC, FCAHS
Assistant Dean, International Affairs
Professor of Family Medicine, Medicine (Geriatrics) and Oncology
Institute for Health and Social Policy
Faculty of Medicine and Health Sciences
McGill University
WHO Bogota 23.3.23

2. No Financial/Business
Conflicts to declare
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3. Canadian healthcare system(s)
◆National «principles» ( public administration ,
comprehensiveness, universality, portability,
accessibility) but decentralized provincial
management
• Provincial rather than national AD plans
◆Quebec Plan (2009) implementation since 2011
◆Ontario bottom up initiatives;
◆Other provinces at various stages of preparing or
implementation of their plans
◆Approaches similar
3

4. Primary care as the way forward
Quebec (and Canada) are distinct
Canadian Consensus Conferences recommendations
since 1989
• Primary care MD: first contact, has patient and family longitudinal
experience; best trained and equipped for community older
persons with multi-morbidity
• There will never be enough specialists interested and trained in
AD and memory clinics may not be more effective-Meeuwsen et al
BMJ,2012; Le Couteur et al BMJ 2013
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5. Primary care as the way forward
Quebec (and Canada) are distinct
◆ Possible now with primary care reform (medical
home)
• Family Medicine Groups (GMF): group practice, team based,
interdisciplinary (nurse clinician/practitioners, social worker,
pharmacists)
◆ Continuity/primary care: lower costs, ED use
hospitalizations, mortality; improved quality
Basu, JAMA Internal med 2019; Bazemore Ann Fam Med
2018; Delgado, Br J Gen Pract 2022; Godard-Sebillotte, JAGS 2021
5

6. Meeting the Challenge of
Alzheimer’s Disease and
Related Disorders
A Vision Focused on the
Individual, Humanism, and
Excellence
REPORT OF THE COMMITTEE OF EXPERTS FOR
THE DEVELOPMENT OF AN ACTION PLAN ON
ALZHEIMER’S DISEASE AND RELATED
DISORDERS
HOWARD BERGMAN, M.D., CHAIR
May 2009
Mandate from the
Quebec Minister of
Health
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7. Seven priority actions
24 recommendations
1. Raise awareness, inform and mobilize.
2. Provide access to personalized, coordinated assessment and
treatment services for people with Alzheimer’s and their
family/informal caregivers.
3. In the advanced stages of Alzheimer’s, promote quality of life and
provide access to home-support services and a choice of high-
quality alternative living facilities.
4. Promote high-quality, therapeutically appropriate end-of-life care
that respects people’s wishes, dignity and comfort.
5. Treat family/informal caregivers as partners who need support.
6. Develop and support training programs.
7. Mobilize all members of the university, public and private sectors,
for an unprecedented research effort.
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8. Access to personalized, coordinated evaluation and
treatment
The Challenge
◆Poor access to:
• Diagnosis, treatment (including behavioral issues), support for
patients and their caregivers
• Integrated management through the stages of the disease
 Including in crises
◆Memory clinics cannot handle the volume nor assure
comprehensive continuity of care
• Resulting in very long waiting lists, delayed diagnosis and late
intervention
◆ Primary care generally not prepared to deal with
patients with ADR
◆ Many patients are not diagnosed or diagnosed late
8

9. Objectives: Provide access to
personalized, coordinated services
◆Rapid access to assessment and management of the
disease following a comprehensive process
• Pharmacological, psychological, social and environmental
approaches
◆Personalized management and innovative access
through a trusting relationship between
patient/family and a credible clinician
▪ With personalized access to a flexible range of primary
care and community well as specialized services
9

10. Objectives: Provide access to
personalized, coordinated services
Anchored in Primary care:
◆enable/empower GMF primary care clinicians to
detect, Dx, Tx, follow vast majority of AD
◆ MD-Nurse-SW-pharmacist)
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0

11. Collaborative care model
partnership patient/caregiver and clinician team
◆Approach based on the
chronic disease collaborative
care model implemented in
Family Medicine Groups
(GMFs)
◆Patient-centred approach;
not disease centered
◆By patient’s treating
MD/Nurse (acting as pivotal
navigation nurse);
SW/pharm
◆Diabetes vs Cancer model
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Patient -
Caregiver
Family
Physician Nurse/SW
Family Medicine Group
Case finding - diagnostic
Treatment - follow-up
Specialized
services –
Memory clinic
Home-based services,
community pharmacy, hospital,
Alzheimer society
Support/Complex cases Coordination - transition

12. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
Ministerial policy decision
• Quebec Alzheimer Plan is a
priority
• A modest but recurrent budget
Some Key Messages
Policy
12

13. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
Ministerial policy decision
• Anchored in primary care and
• based on a person-centred approach
(vs a disease centred approach);
• Enable/empower the patient’s
PCP/FMG Team
Some Key Messages
Policy
13

14. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
An implementation plan with an
ambitious change management
strategy with associated funding
• Active ministerial role in inspiring,
stimulating and supporting change
• Ministry leadership with inclusive
stakeholder governance
• Diversity in application: one size
does not fit all
Some Key Messages
Policy
14

15. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
• Integrating research providing
collaborative «developmental»
evaluation
• feed back to ministry and clinical sites
• A sequential approach to implementation
in 3 phases
• Phase I shed light on innovative
projects/approaches, mobilised clinicians and drew
key lessons to support scaling up (phase II and III)
Some Key Messages
Policy
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16. distinctive implementation strategy
A sequential approach to implementation in 3 phases
• 2009-Plan is tabled
• 2011-Ministerial decision based on Qc AD plan
recommendations
• 2011-12 Pre implementation phase
• 2012-16 Phase 1- targeted implementation with independent
peer review evaluation to improve and scale up
 Implementation projects in 40 GMF’s-urban, rural, remote chosen by
«competition
• 2017-20 Phase 2-Scaling up
• 2021- Phase 3- Post-COVID; transitions; behavior
manifestations 16

17. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
• A “pre-implementation” study and consultations
with clinicians
• Mobilization of “Clinical Champions” (1st care &
2nd/3rd care)
• Capacity building strategies (training,
dissemination of clinical tools etc…)
• Commitment of university partners
• 4 project managers to support implementation
Some Key Messages
Initial implementation
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18. Équipe de Recherche en
Organisation des Services sur
l’Alzheimer
Research Team on
Organization of Healthcare
Services for Alzheimer's
Produce rapid and pertinent results for stakeholders:
patients-caregivers-citizens, decision makers, managers and clinicians
Canadian Team for healthcare services/system improvement in dementia care

19. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
Three interrelated cross-fertilizing studies
• To identify the impact of the QC Alzheimer plan on
detection, diagnosis, referral patterns, and quality of
follow-up
OBSERVATIONAL
(Quantitative) Study
• To examine the implementation strategies used in
order to identify key factors for successful
development and large-scale up-take across Canada
IMPLEMENTATION
(Qualitative) Study
QUALITY OF CARE AND USE OF HEALTH SERVICES
Administrative databases
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20. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
• Baseline*
• very good to excellent clinical knowledge
• Positive attitudes to disease, AD Plan
• Strongly support/appreciate/use interdisciplinary approach
and access to MD and nurse expertise within the GMF
• Identification of a champion in the FMGs
• Although received late, appreciated pathway/guidelines,
training as well as access to outside expertise
• Leading to increase competency and confidence
• Critical about delay to access memory clinic and home care
*Arsenault-Lapierre G, Henein M, Rojas-Rozo L, Sourial N, Bergman H, Couturier Y, Vedel I. Primary care
clinicians' knowledge, attitudes, and practices concerning dementia: They are willing
and need support. Can Fam Physician. 2021
Some Key Results/Impact
Clinicians in the FMG
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21. Research on organization of healthcare services for Alzheimer’s
Canadian team for healthcare services/system improvement in dementia care
Primary care (GMFs) can detect, diagnose, manage and meet the
needs of persons living with dementia and their caregivers
• offering high quality care
• utilising specialty care for complex cases
A person-centred interdisciplinary approach by the patient’s
treating MD/clinical team resulted in
• Improved continuity of care
• Higher intensity of follow-up
• Improved quality of care
• Fewer/more appropriate specialist referrals
• Decrease ED visits and hospitalization
Room for improvement
• antipsychotics prescriptions
• evaluation of caregiver needs
• referral to community services
Vedel I, Sourial N, Arsenault-Lapierre G, Godard-Sebillotte C, Bergman H. Impact of the Quebec
• Alzheimer Plan on the detection and management of Alzheimer disease and other neurocognitive
• disorders in primary health care: a retrospective study. CMAJ Open
Some Key Results/Impact
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22. Significant challenges
• From targeted projects to generalization
• Beyond initial innovators/leaders/champions
• MD mobilization/buy-in
• Transitions
• Behavior manifestations
• Role of persons living with dementia and
their caregivers
• Advent of Bio-markers/disease modifying
medications-the challenge of access and
equity
• Medically assisted Dying
• Post-COVID
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23. Key elements for successful implementation
1. Clear ministerial decision
• Integration into the ministry programing
• Recurring budget, even if modest
2. An implementation plan
• With priorities (not too many at the same time)
• Change management strategy
 Support/stimulate change
• Diversity in application: one size does not fit all
• Phased implementation
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24. Key elements for successful implementation
3. Ministry leadership with inclusive stakeholder
governance
• Credible «extra- ministerial» clinical leadership
• Mobilize clinician champions
• Mobilize university and civil society
4. Guidelines necessary but not sufficient
• Clinical pathways
• Training
• Get into the trenches
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25. Key elements for successful implementation
5. Independent evaluation to support and adapt
implementation
• Integrate university researchers; feed back to ministry
and clinical sites
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26. Acknowledgements
Isabelle Vedel MD, PhD
Yves Couturier, Ph.D.
Maxime Guillette Ph.D. (cand)
Carolyn Boudreau, Minisitry
And
ROSA Research Team
Stakeholder partners
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Canadian Team for healthcare services/system improvement in dementia care
https://www.mcgill.ca/familymed/research/projects/research-organization-healthcare-services-
alzheimers-rosa

27. Muchas gracias
Merci
Thank you
2
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28. Interdispinary clincial pathways
• https://www.mcgill.ca/familymed/fil
es/familymed/interdisciplinary_clinical
_process_diagnostic.pdf
• https://www.mcgill.ca/familymed/fil
es/familymed/interdisciplinary_clinical
_process_follow-up.pdf
Useful links
Interdisciplinary clinical pathways
Policy lessons
https://www.healthcareexcellence.ca/en/what
-we-do/what-we-do-together/the-quebec-
alzheimer-plan-sharing-the-experience-of-its-
implementation-to-strengthen-primary-care/

29. 29
https://cahs-acss.ca/improving-
the-quality-of-life-and-care-of-
persons-living-with-dementia-
and-their-caregivers/

30. • key determinants linked with indicators of access to
and use of services (e.g., continuity of care with the
family physician, potentially avoidable ED visit &
hospitalization, potentially inappropriate medication,
long-term care admission):
o Sex and gender
o Rurality
o Socioeconomic status
o Racialized and immigration
o COVID impact
o Post-dx care
o Living Lab
ROSA Group
Other studies
https://www.mcgill.ca/familymed/
research/projects/research-
organization-healthcare-services-
alzheimers-rosa