Table 4.

Rural memory clinic team members' perspectives of factors influencing sustainability and spread and associated RaDAR activities

Factors influencing sustaining and spreading memory clinics	How it helps	RaDAR Strategies supporting sustainability and spread of rural PHC memory clinics
BOTH SUSTAIN AND SPREAD
Positive outcomes for patients & families	-rural communities aging but have limited services -knowing that the clinic is addressing gaps and meeting needs in the community makes teams want to start a clinic and to continue - community awareness that help is available leads to continued referrals -patient and family more comfortable with familiar health care team members -clinics avoid travel/wait times for urban specialists -clinics provide “one-stop shop” with access to all services and provide “wrap-around” support -families feel relief at getting help and less alone and isolated; they know where to go for help -clinics are resulting in earlier diagnosis and management, provision of supports, less stigma	-collecting research data on clinic outcomes that are shared with teams in reports and presentations; reinforces positive impact of the clinics -teams have presented on their clinics and the benefits at the annual RaDAR Rural Dementia Summits and national conferences
Well-developed clinic processes and tools	-clinic has core components but is adaptable depending on available health care professionals -everything needed is ready to use -less daunting to start a clinic -less time investment required by teams than trying to start a memory clinic on their own -standardized process provides structure to follow -reduces uncertainty about what is expected -education sessions build capacity and confidence -clinics are more efficient for some team members	-collaborated with teams to adapt PC-DATAa [39] flow sheets for team-based care in rural context and embed in EMR -created clinic Handbook compiling all clinic resources; provided copy to each team member; updated annually -supported team members to visit specialist memory clinic at university, attend annual RaDAR Summit, and travel with RaDAR to national conferences -researchers shared innovations developed by teams with other teams
Clinic champion and engaged confident leader	-confident, enthusiastic leader acts as a champion for new teams, creating interest and excitement -clinics need a consistent leader who knows the clinic processes and provides direction -clinic leads need skills in both dementia care and leadership in order to lead the implementation	-support clinic leads to develop capacity, e.g., attend dementia conferences, attend RaDAR training sessions
Facilitation and problem-solving	-local PHC facilitator (health region position) helps with communication, scheduling clinics and meetings, developing clinic resources/processes -local facilitators have coordination and quality improvement role, so it is good fit with the clinics -Facilitators and researchers help trouble-shoot and problem-solve to resolve problems early -RaDAR team facilitation keeps teams accountable	-hired Team 1 nurse practitioner part-time to provide leadership and clinical support to teams -hired former Team 1 facilitator living near the teams to attend all clinics, provide operational guidance and collect research data -hold regular workgroup meetings with teams following each clinic to debrief, and problem-solve -hold monthly “check-in” meetings with PHC facilitators and managers to identify/address sustainability issues
Organizational and leadership support	-manager support gives team members permission to engage in developing and practicing in the clinics -access to resources is driven by health system strategic priorities and direction of leadership -health region reorganization underway aligns with the clinic goals of team-based care	-RaDAR research guided by a Steering Committee of all regional Directors and Alzheimer Society leadership -Primary healthcare directors and managers invited to regular team workgroup meetings -connected with provincial health authority leadership to consult about spread strategies
SUSTAIN
Team passionate and engaged	-commitment and belief in the program help teams collaborate to refine and adapt clinic processes -engagement creates motivation to make the clinic a priority as other demands on teams increase -maintaining a cohesive team requires shared decision-making so all members feel involved -determination to continue during the Covid-19 pandemic shown by adapting to new restrictions	-hold regular workgroup meetings with memory clinic teams and RaDAR researchers to facilitate team communication and decision-making, and keep clinic front of mind
Continuity of team members	-recruitment of healthcare professionals in rural areas can be challenging thus consistency of members helps clinic run smoothly -experienced team members are able to support a new clinic lead while they gain experience	- the clinic handbook is a resource for new members -the EMR manager orients new team members to PC-DATA [36] in the EMR -researchers help orient new facilitators to the clinic -researchers provide 1–1 and group orientations -clinic leads are essential in orientation
Positive outcomes for team members	-team members are more comfortable with each other and working together -collaborations have spread to work outside clinic -team members are more aware of each other’s practice and contributions to dementia care -team members have more information to work with, improving individual/joint recommendations -Alzheimer Society can establish relationship with patient and family to discuss needs and supports -clinics are efficient for some team members because assessments and planning are coordinated in one visit -team approach is gold standard; takes pressure off individual members for issues such as driving	-regular workgroup meetings helps teams to continually improve care coordination -researchers provide regular reports on clinics to the Steering Committee and health authority leadership, underscoring the valuable service teams are providing
SPREAD
Sustained, successful pilot clinic	-demonstrates that clinic is possible in small rural community and is effective -pilot clinic’s success motivates new teams to start, appeals to team competitiveness -pilot clinic members can engage colleagues in other communities to stimulate interest	-supported development, printing, and distribution of a brochure describing rural PHC memory clinic goals, referral process, assessment process, and benefits. -funded a professional video of a clinic day to raise awareness in community and health care https://www.youtube.com/watch?v=Tzr1MVu7Mpc -memory clinic teams present at annual RaDAR Rural Dementia Summit to share clinic processes, successes
Identify teams with interest, capacity and resources	-focus on teams with interest and resources because both are needed to thrive and survive -let new teams know team composition is flexible -ensure potential new teams are aware of benefits for patients, families, and their own practice -spread is facilitated when there is overlap of team members between new and existing teams	-meet with regional Directors and Managers to identify potential new teams with interest/capacity to start clinic -provide resources to teams where needed to address gaps, such as conference phones, laptops -identifying and engaging teams with interest is part of role of the Team 1 nurse practitioner (hired part-time by RaDAR).
Shadowing and mentoring opportunities	-the most effective strategy for inspiring new team members is to observe a clinic in action to see the value for patients, families, and team members -connecting new members with their counterpart on an existing team helps orient and educate about their role, and provides reassurance	-shadowing and mentoring is built into planned spread strategy: Team 1 nurse practitioner and former team facilitator hired by RaDAR to support teams in starting up and sustaining clinics; new members will be matched with experienced counterpart mentor; opportunity for new members to shadow existing clinics. -delivered initial and ongoing education sessions

^aPC-DATA™ Primary Care Dementia Assessment and Treatment Algorithm [39]