Table 2.

Quebec Alzheimer Plan: Design and policy environment.

	SEGMENTATION	COORDINATION	ENGAGEMENT	SUCCESS MEASURES	POLICY-RELATED CONTEXT
Description	Defining and applying rules to identify and recruit patients who are likely to benefit	An intake process to characterize needs, mechanisms for coordination across institutions and sectors such as health and social care	Support for shared decision-making, self-management and support for caregivers	How programs defined success, their level of maturity and any evaluation work conducted	Policy innovation to support integrated health and social care, and innovation in care delivery
	Target group: Patients with major neurocognitive disorders (Alzheimer’s disease and other NCD) and their caregivers.	Intake: In case of clinical suspicion, a comprehensive assessment of mental and cognitive states and depression is conducted by the GP-RN duo, using validated tools such as MMSE, MoCA and GDS-15 or GDS-5. RNs also assess the patient’s functional ability (ADL, IADL) and their health and social care needs. A diagnosis is made based on the disease history, cognitive and functional decline results.	Patient engagement: The QAP promotes the autonomy, independence and participation of patients and caregivers. In the clinical context, patients’ priorities are assessed and their choices are taken into consideration for the decision-making process.	Maturity: The QAP is currently well established and mature after its second implementation phase. This phase was rather a progressive development of best practices, on a provincial level, through access to an implementation guide, training and a change management strategy.	Financing for model: Public funding. For the pilot phase (2014–2016), an annual budget of five million dollars was allocated by the MSSS to implement the QAP in 19 selected projects. Each project received $250,000 per year (over 2 years). A recurring budget ($225,000 per regional health authority) was allocated afterwards to support the deployment of best clinical and organizational practices in all regional health authorities throughout Phase 2. Sustainability of the QAP is ensured through recurrent funding (dedicated to staff professional development) and the allocation of regional nurses mandated to train staff and update training content. It should be noted that the allocated amount has remained the same but is now spread over many more FMGs.
	Entry points: Self-referral (patients and families) or by professionals who suspect a neurocognitive disorder. Although systematic screening is not recommended, a vigilance zone is applied for those at high risk (65 years old and above with risk factors; 75 years old and above who renew their driving licence).	Primary care providers: A GP-nurse partnership with the patient and their caregiver is established. These two primary care providers are responsible for early diagnosis, treatment (if needed), management and referral of patients to relevant providers and services, especially referral to cognition clinics for complex cases. Other care providers (social workers, occupational therapists, pharmacists, special education technician) were added to the existing teams and located either in primary or specialized care or shared by the two levels of care. Unfortunately, little effort was put into coordination with regional health authority programs aimed at supporting the autonomy of the older people.	Patient self-management: This is sometimes difficult to operationalize given their functional and cognitive status. Patient education, support and counselling are provided by nurses during regular follow-up visits.	Measures (current goals): Although the plan’s recommendations cover the continuum of care, the implementation strategy promotes building the capacity of FMGs to ensure the early diagnosis and overall monitoring of people with Alzheimer’s and their caregivers in the community.	Staffing model: The pilot projects resulted in the addition of at least one nurse per project, eight social workers, a few occupational therapists, a pharmacist and a special education technician. These professional resources were added either to the IHSSC, to the FMGs, or shared between the FMGs and the specialized organizations. Only a few were assigned to specialized organizations. Part of the budget of the deployment phase was used to train and provide equipment to healthcare providers. The RNs kept their initial caseload of patients and were trained to pay particular attention to patients who present signs of AD or were at high risk.
		Integration: Available personalized and coordinated services include (to varying degrees) primary care in the community, psychosocial resources such as Alzheimer Society support centres, home care programs, specialized care such as specialized memory clinics and specialized teams dedicated to behavioural and psychological symptoms of dementia.	Caregiver engagement: This is a major component of the QAP as caregivers are considered valuable partners. For instance, they are actively involved in monitoring changes in the patient’s cognitive and functional status. Caregivers are also entitled to psychoeducational and support services to help them cope with the patient’s condition, better navigate the health system and the community network, and establish an end-of-life plan. When deemed necessary, RNs proceed with an assessment of the caregiver’s burden. Patients and caregivers were not involved in the co-design of the first phase of the QAP. However, Phase 2 involved patients’ and caregivers’ representatives (Alzheimer Society) in the development plan.	Data collection: This was done to varying degrees in the FMGs. The recommended indicators were difficult to collect or perceived as irrelevant by the FMGs. They prioritized staff training in assessment and identification of patients with AD, and teamwork. Therefore, they collected process indicators on these two variables (i.e number of staff trained). There were also difficulties with collecting harmonized data across all FMGs. Finally, data collection was assigned to RNs. Their overloaded schedule and turnover impeded the process.	Governance structure: Shared governance model combining top-down components and a bottom-up approach. National priorities were established by the MSSS (who set up a committee including partners and researchers), and professionals were asked to design their local projects according to their local realities while still aiming to achieve the objectives identified by the MSSS. Professionals received the support of designated project managers for coordination in terms of governance and change management.
		Transitions: The presence and use of a referral process and a structured protocol for care transitions across sectors or care settings varied between settings. Overall, RNs worked as patient navigators and advisors. They linked patients and their caregivers with home care, community care and specialized services but played a minimal role in optimizing transitions in the event of hospitalization.		Evaluation: A continuous evaluative study was set up during project implementation to enable monitoring and progressive adjustment of service structures based on the challenges posed by their implementation, and to support their transferability to other contexts. Evaluation of Phase 1 focused on the impact of the QAP on the quality of services provided by FMGs. Evaluation of Phase 2 focused on monitoring change management.	Health and social care data sharing: Although it was one of the recommendations, no innovative approach for sharing data across providers and settings was established. This was mainly due to the lack of interoperability with the existing EHR.
		Information sharing: A common EHR allows information sharing between healthcare professionals within an FMG. There is no operational common data platform for sharing data across providers and settings. Communication is considered suboptimal by providers. Channels mainly include referral letters and reports.			Care delivery innovation: The 19 pilot projects all presented innovations in the health and social services network, the main objectives of which are to diagnose AD and other major NCD more quickly in primary care, as well as to improve follow-up, in the community (as opposed to the specialized care level), with people with Alzheimer’s and their caregivers. Decentralization of clinical governance enabled the development of a broad diversity of innovative projects.

AD: Alzheimer’s disease; ADL: activities of daily living; IADL: instrumental activities of daily living; GP: General practitioner also known as family physician; MMSE: Mini Mental State Examination-Folstein; MoCA: Montreal Cognitive Assessment; GDS-15 and GDS-5: Geriatric Depression Scale; MSSS: Ministry of Health and Social Services. IHSSC: Integrated health and social services centres; IUHSSC: Integrated university health and social services centres; NCD: Neurocognitive disorders.