Photo caption: (left to right) Jennifer Koop, Advanced Practice Nurse in the Division of Geriatrics at The Ottawa Hospital, and Dr. Matthew Sacheli, Program Manager at the Regional Geriatric Program of Eastern Ontario.
In July 2024, The Ottawa Hospital (TOH) launched Dementia Decoded, one of the first strategies in Canada to focus specifically on caring for patients with dementia in an acute care setting.
The strategy was born from an urgent need. An estimated 770,000 people are living with dementia in Canada — and by 2050, that number is projected to more than double. The growing prevalence of dementia will place mounting pressure on acute care settings, as hospital systems will shoulder much of the burden. Reflecting the national landscape, data from TOH shows that patients with dementia stay 2.8 times longer in hospital than patients without this condition and are 1.6 times more likely to experience an adverse event, such as delirium, falls and functional decline.
Dementia Decoded is a joint initiative from TOH and the Regional Geriatric Program of Eastern Ontario (RGPEO). Built on person-centred care and three key pillars, this comprehensive strategy seeks to transform care for people living with dementia to enrich the lives of patients, caregivers and staff alike.
Pillar #1: Getting to know the person behind the diagnosis
The Dementia Decoded team’s first step was creating a way for our staff to easily identify patients with dementia and efficiently document their care needs. Since July 2024, patients with dementia are identified in the Epic health records system by a “D” icon and a banner reading, “Person living with Dementia – update care needs.” When the health care provider clicks on the banner, they are led to the Accessibility Form, which now features a behavioural and care needs section, where they can note any details that may help in the delivery of person-centred care, including the patient’s likes, dislikes, family members, mobility needs, spiritual needs and even hobbies and previous career.
“The foundation of improving dementia care is understanding who the person is,” explains Jennifer Koop, Advanced Practice Nurse in the Division of Geriatrics at TOH. “That means recognizing the things that may cause them distress and the things that can comfort them. And when we ask patients and their caregivers these important questions at the very beginning of the care journey, it opens the lines of communication and helps ensure they are part of the care team.”
Pillar #2: Enhanced Care Planning
With proactive care planning being so beneficial to this patient population, the Dementia Decoded team collaborated with TOH’s Nursing Professional Practice Department to create a new Epic care plan activity specifically for dementia care. The new care plan empowers health care teams to proactively develop interventions that help achieve patient goals and improve outcomes — based on best practice guidelines for dementia care and the person-centred details collected in the patient’s accessibility form.
The new Epic care plan is set to be piloted this fall in select units across TOH and at select sites across the Atlas Alliance, a network of health care organizations using Epic. The feedback from this trial will help the Dementia Decoded team fine-tune the care plan before rolling it out wide across our hospital.
Pillar #3: Educating and Empowering Staff
Inspired by Scotland’s national dementia strategy, the Dementia Decoded team created the Dementia Champion Program, which provides frontline staff with enhanced training in dementia care (through the delivery of the renowned Gentle Persuasive Approaches Course from AGE Inc.) and an introduction to the revamped care plan tools in Epic.
A pilot project rolled the training out to staff on the Geriatric Medicine Unit, who later reported increased confidence in caring for patients with dementia. And after well-received training sessions in our emergency departments, the Champion Program is now part of the standard orientation for ED nurses, improving dementia care from a common point of entry to the hospital.
The Champion Program will be piloted concurrently with the new care plan across TOH and participating Atlas Alliance partners.
Setting a New Standard for Dementia Care
The Dementia Decoded team is working to expand the strategy to hospitals across the Champlain region via the RGPEO — and eventually across the province and the country.
“Dementia Decoded has the potential to become the standard of care for hospitals throughout the province and beyond,” says Dr. Matthew Sacheli, Program Manager at the RGPEO. “We are one of the first groups in Canada to launch an acute care dementia strategy, so other hospitals are looking at Dementia Decoded as a model to replicate. We first want to extend the strategy’s reach across the region and then create a playbook that other health care organizations across the country can follow to improve dementia care in their own acute care settings.”
To learn more about Dementia Decoded, please visit the RGPEO website and watch this video online.