Project ECHO Integrated Seniors Care
All Teach, All Learn
Bridging the Knowledge Gap in Home and Primary Health Care
Through CHCA Project ECHO, we envision a future where all patients receive high-quality care, no matter where they live. Our innovative learning approach strengthens provider competencies by building essential skills, knowledge, and attitudes through education, best practices, and collaborative networks. Our goal is to improve care quality, strengthen clinical practice, support confidence and collaboration, and ultimately deliver better outcomes for patients and their families.
2025 Theme:
Multimorbidity and Cognitive Decline
Join us for our new Project ECHO: Integrated Seniors Care series, focused on strengthening care for older adults living at home with multimorbidity and cognitive decline. With 37% of Canadian seniors reporting two or more chronic conditions, and many also experiencing undiagnosed cognitive impairments, an interdisciplinary, team-based approach is essential. This TeleECHO series will feature expert-led presentations and dynamic panel discussions exploring practical strategies, clinical challenges, and collaborative solutions to support seniors with complex needs, including dementia, in home and primary care settings.
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These activities meet the certification criteria of the College of Family Physicians of Canada and the Quebec College of Family Physicians, a continuing professional development accrediting organization recognized by the Collège des médecins du Québec and have been approved for up to 8 Mainpro+® Certified Activity credits. |
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Coordinating Transitions in Complex Dementia and Multimorbidity Cases
November 26, 2025 | 12–1pm Eastern (confirm time in local area)
Caring for individuals living with dementia alongside multiple chronic conditions often involves navigating frequent transitions between support services. Without strong coordination, these transitions can be fragmented, leading to gaps in care and increased stress for families.
This session focuses on how primary care and home care teams can work together to manage complex cases by building shared care plans, strengthening referral pathways, and engaging community supports. Through real-world examples, we’ll explore strategies for improving communication, reducing duplication, and fostering shared accountability across services to ensure continuity for patients and families.
Subject Matter Expert: Dr. Ivy Oandasan
Panelists: TBC
*This session is offered in English, with multilingual captioning available.
1 Mainpro+® Certified Activity credits.
Navigating Autonomy and Safety in Complex Care
December 10, 2025 | 12–1pm Eastern (confirm time in local area)
Balancing client autonomy with safety is one of the most ethically complex challenges in dementia care. This session explores how interprofessional teams can apply legal and ethical frameworks – such as capacity, consent, and duty to act – to support person-centred decision-making. Through real-world examples, we’ll examine how teams can foster shared responsibility, use structured dialogue to navigate tensions, and build trust while honouring both client preferences and clinical responsibility.
Subject Matter Expert: Dr. Kerry Bowman
Panelists: Olesya Kochetkova, additional panelist TBC
*This session is offered in English, with multilingual captioning available.
1 Mainpro+® Certified Activity credits.
Assessing Frailty in Complex Care: Balancing Risk, Judgment, and Care Planning
January 21, 2026 | 12–1pm Eastern (confirm time in local area)
Frailty assessment is more than scoring, it’s a conversation that informs care planning. This session explores how tools like the Pictorial Fit-Frail Scale (PFFS) support meaningful assessment, the role of professional judgment, and the importance of understanding how older adults perceive risk. Drawing from the “Dignity of Risk” program, we examine how respectful dialogue and proactive planning can reduce stigma, increase engagement, and support person-centred decisions across home and primary care settings.
Subject Matter Expert: Dr. Kenneth Rockwood
Panelists: TBC
*This session is offered in English, with multilingual captioning available.
1 Mainpro+® Certified Activity credits.
Past TeleECHO Clinics
Strengthening Team Communication Through Role Clarity
October1, 2025
Madelaine Meehan shared lessons from Ontario’s primary care pathways, emphasizing collaboration, shared accountability, and direct communication. Judy Stewart and Karen Bell joined the case study discussion of how clear roles, cultural awareness, and caregiver support enhance coordination, reduce fragmentation, and improve outcomes for patients receiving home and community care.
Caring Together: Integrated Approaches to Support Responsive Behaviours in Dementia Care
June 25, 2025
Kim Shryburt-Brown explained that responsive behaviours in dementia reflect unmet needs. She reviewed early warning signs, non-pharmacological interventions, and tools like the BSO-DOS and PIECES framework. The case study panel discussion with Claire Webster, Jillian McConnell and Ashley Lewis emphasized cultural competence, caregiver education, and proactive planning as essential for collaborative, person-centered dementia care and building trust.
Respecting Diverse Perspectives in Shared Decision-Making
June 9, 2025
Dr. France Légaré shared research and tools to support shared decision-making in seniors’ care. Through a panel discussion, Dr. Yinka Akin-Deko, Tashani Parker, and Wendy Gairy explored a complex case, highlighting cultural values, cognitive decline, caregiver stress, and system gaps. The session emphasized collaboration, person-centred care, and respecting diverse perspectives in planning and delivering care for older adults
Integrated Dementia Care: Equipping Teams for Early Recognition and Action
March 27 2025
Dr. Robert Lam, MD, MS, CCFP, FCFP (Care of the Elderly), Staff Family Physician, Home-Based Primary Care Team, Unison Health & Community Services, provided practical strategies for identifying early dementia signs, using effective screening tools, communicating red flags, implementing care strategies, and approaches to delivering person-centred, non-pharmacologic and pharmacologic interventions.
Linking Healthcare and Community: Social Prescribing in Integrated Senior’s Care
Feb 12, 2025
Krista Mulbery, Social Prescribing Project Manager, Edmonton Seniors Coordinating Council, Colleen Derksen, Social Work Manager, Sage Seniors Association, and Tatiana Kastner, Program Manager for Older Adult Services, Jewish Family Services Edmonton, discussed the profound impact of collaborative social prescribing and integrated health and community services on the well-being of seniors living with dementia.
TeleECHO Clinic
Expert Presentation Slides
Evidence-Based Resource
Interdisciplinary Collaboration for Seniors with Cognitive Impairment
January 22, 2025
Tim Stultz, MD, Medical Director of the COACH Program, and Amy Garrett, Nurse Practitioner, Provincial Geriatric Program, Summerside, PEI, shared their expertise on improving care for older adults through COACH’s interdisciplinary collaboration, with a focus on essential skills, knowledge and attitudes.
TeleECHO Clinic
Expert Presentation Slides
Evidence-Based Resource
Building Competencies in Integrated Care: Lessons from Vancouver’s Home ViVE Program
December 4, 2024
Dr. Judith Hammond, MD, Dr. Conrad Rusnak, MD, and Joti Bagri, RN of Vancouver’s Home ViVE program shared practical insights into team-based, interdisciplinary care highlighting the skills, knowledge and attitudes needed for an integrated approach to care.
TeleECHO Clinic
Expert Presentation Slides
Evidence-Based Resource
When is it Normal, Mild Cognitive Impairment or Dementia?
October 1, 2024
Dr. Andrew Kirk, MD, FRCPC, Professor and Head of Neurology at the University of Saskatchewan, and Jennifer Letkeman, BSW, RSW, Primary Health Care Facilitator at Weyburn Special Care Home, discussed the early identification and management of dementia, including recognizing risk factors, identifying early warning signs, and developing a collaborative approach to screening, diagnosis, and treatment.
TeleECHO Clinic
Expert Presentation Slides
Evidence-Based Resource
Continue your learning
The Project ECHO Home and Community Care Learning Hub offers a variety of resources for healthcare providers delivering home- and community-based care. Through the hub, you can access:
- On-demand TeleECHO session recordings that feature expert presentations and case-based discussions.
- Presentation slides from subject matter experts
- Evidence-based resources, including articles and reports supporting clinical practices.
- 10-minute micro-learning courses on key learning content for a selection of TeleECHO topics.
To access the Learning Hub: https://echo.cdnhomecare.ca/
Project ECHO Integrated Seniors Care is made possible through the support from the Canadian Medical Association in partnership with the Canadian Home Care Association.
The Palliative Care ECHO Project is supported by a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
Strengthening Team Communication Through Role Clarity
October 1, 2025 | 12–1pm Eastern (confirm time in local area)
Effective dementia and multimorbidity care requires clear roles and strong interprofessional communication. This teleECHO clinic explores strategies—shared care plans, digital tools, mutual respect—to enhance coordination, reduce duplication, and build trust. A panel discussion of the case study will highlight role clarity, shared planning, and accountability across home and primary care to improve person-centred, integrated team performance.
Subject Matter Expert (SME): TBD
Panelists: Judy Steward, Karen Bell
*This session is offered in English, with multilingual captioning available.
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This activity meets the certification criteria of the College of Family Physicians of Canada and the Quebec College of Family Physicians, a continuing professional development accrediting organization recognized by the Collège des médecins du Québec and has been approved for up to 8 Mainpro+® Certified Activity credits. |
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This activity meets the certification criteria of the College of Family Physicians of Canada and the Quebec College of Family Physicians, a continuing professional development accrediting organization recognized by the Collège des médecins du Québec and has been approved for up to 8 Mainpro+® Certified Activity credits. |
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This post is also available in: French
Established in 1990, the Canadian Home Care Association (CHCA) is a national non-profit membership association dedicated to advancing excellence in home and community care.
National Office: 905-567-7373 | General Inquiries: chca@cdnhomecare.ca
2000 Argentia Road, Plaza 3, Suite 302. Mississauga, ON, L5N 1W1
This post is also available in: French