Collaborative Dementia Care Models in Primary Care

Collaborative dementia care models in primary care represent a structured approach to the identification, management and support of individuals living with cognitive impairment and their families. These models integrate multidisciplinary teams—typically comprising general practitioners, nurses, social workers, pharmacists and community health workers—to deliver coordinated, person-centred services within the familiar setting of the patient’s medical home. Key components include proactive case finding through routine cognitive screening, shared care planning with patients and caregivers, streamlined communication pathways between primary care and specialist services, and the incorporation of psychosocial and community resources. By harnessing information technology and data-sharing platforms, these models aim to optimise treatment of behavioural and psychological symptoms, promote medication review, facilitate advanced care planning and reduce unplanned hospital admissions. International examples have demonstrated improvements in caregiver satisfaction, delayed functional decline and cost efficiencies, highlighting the global relevance of these approaches in addressing the rising prevalence of dementia and the strain on health systems.

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Collaborative Dementia Care Models in Primary Care publication trend

The graph below shows the total number of articles in collaborative dementia care models in primary care across all publications each year (not limited to Nature Index journals).

Technical terms

Collaborative care model: an interdisciplinary framework in which primary care providers, specialists and community services share responsibility for comprehensive patient management.

Care coordination: the deliberate organisation of patient care activities and information sharing among all participants involved in a person’s care to achieve safer and more effective outcomes.

Care navigator: a non-clinical or clinical professional who guides people with dementia and their families through health and social care systems, ensuring access to appropriate services and support.

Multidisciplinary team: a group of healthcare and social care professionals from diverse disciplines working collaboratively to address the complex needs of people with dementia.

Advanced care planning: a process by which individuals with cognitive impairment, together with their caregivers and healthcare providers, discuss and document future health and personal care preferences.

References

1. Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults. Geriatrics (2019).
2. Impact of dementia care training on nurse care managers’ interactions with family caregivers. BMC Geriatrics (2023).
3. Evaluation of a care management program on family caregivers of persons with dementia. Geriatric Nursing (2023).