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Primary Care Memory Clinics in the Champlain

Dr. Linda Lee

Linda Lee, MD, MClSc(FM), CCFP, FCFP
Director, CFFM Memory Clinic
CFFM-RIA Director for Primary Healthcare Education, Schlegel-UW Research Institute for Aging
Associate Clinical Professor, Department of Family Medicine, McMaster University

As the number of persons living with Mild Cognitive Impairment (MCI) and dementia increase, the impact on the lives of many who go undiagnosed becomes more and more apparent to both caregivers and the health care system.

Dr. Linda Lee was one of the many family physicians to experience this first hand. In an attempt to meet the needs of patients, caregivers, and her colleagues at the Centre for Medicine Family Health Team in Kitchener, Dr. Lee developed a primary care model that focused on early diagnostic assessment, treatment and follow up for those living with MCI and dementia. The model was designed to address major barriers to optimal dementia care in primary care practice.

The first Memory Clinic began seeing patients in 2006. Since 2008, 40 primary care memory clinics serving over 500 family practices have been implemented. The aim of the clinic is to increase capacity within primary care practice to assess and manage persons and their family members dealing with memory disorders.

What is a Primary Care Memory Clinic?

The memory clinics are run by family physicians and allied health care professionals who dedicate 1 to 2 days/month to work in memory clinics servicing their primary care practice patients. Each clinic is supported by a specialist for e-mail/telephone support. This support helps to avert unnecessary referrals, improves the skills of the physicians and develops the specialist’s comfort with the team’s skill level. The model builds capacity for care by increasing the ability of family practices to manage the majority of patients while appropriately referring the most complex cases to specialists.

Training for the Primary Care Memory Clinics?

Each clinic completes standardized training accredited through the Canadian College of Family Physicians and offers the same approach to care and evidence-based cognitive testing and intervention. The evaluative studies of this model have demonstrated overall referral rates of 9% while maintaining high quality. The referral rates compare favourably to published referral rates of up to 82% for patients with dementia in traditional family practice models (Pimlott, U of T, 2006).

How does this model build capacity?

This model has been identified as helping to build health system capacity in three ways:

  •  Evaluation has revealed that most referring family physicians reported increased confidence, knowledge, and skill in managing patients with dementia. This model can act as a practice-based mentorship to increase capacity for care among referring family physicians.
  • Primary care memory clinics act as intermediaries between family physicians and other specialists by assessing more complex cases that family physicians might not be comfortable with, providing them with for ongoing care, and referring cases to specialists when necessary.
  • A reduction in referrals builds capacity by decreasing burden on specialist care and reducing wait times for urgent specialist appointments. For referred cases, primary care memory clinics increase specialists’ efficiency by providing them with a detailed history and results of cognitive testing, and allow them to offload back to the memory clinic for ongoing monitoring and management.

Primary Care Memory Clinics in the Champlain Region

Many primary care practices in the Champlain Region have developed their own models for meeting the needs of seniors. As a result, they have built capacity and support for their patients living with dementia and their caregivers. It will take a number of primary care models and community supports to build capacity into the health care system in order to offer persons living with dementia and their caregivers the support they need to navigate the journey. We congratulate all of you in your efforts and thank you for your dedicated resources to this senior population.

As part of the Champlain Local Health Integration Network (LHIN) strategic plan and the implementation of the Dementia Model of Care, the LHIN has provided funding support for training five primary care practices to implement The Centre for Family Medicine Primary Care Memory Clinic model each year for three consecutive years. The five primary care practices in the Champlain Region that will be implementing a Primary Care Memory Clinic in 2013-14 are:

  • Arnprior Family Health Team
  • Connexion Family Health Team
  • Montfort Academic Family Health Team
  • The Ottawa Hospital Academic Family Health Team
  • Southeast Ottawa Community Health Centre

Want to know more?

If you are interested in discussing the Primary Care Memory Clinic model further or would like to complete a readiness assessment for your primary care practice, please contact Kelly Lumley-Leger, Regional Geriatric Program of Eastern Ontario, at: or 613-798-5555 ext. 16464.

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