Project ECHO Integrated Seniors Care
All Teach, All Learn
Bridging the Knowledge Gap in Home and Primary Health Care
Project ECHO Integrated Seniors Care (ISC) is a transformative initiative to enhance primary and home care providers’ skills, knowledge, and attitudes to deliver integrated, patient-centered care for seniors with complex chronic conditions. According to recent surveys, 23% of primary care providers (Commonwealth Fund Survey 2022) and 42% of home care providers (CHCA Survey 2018) report knowledge gaps in meeting the complex care needs of individuals with chronic conditions. Project ECHO ISC offers collaborative, expert-led presentations and case-based learning to bridge these gaps. The Project ECHO Community Hub provides access to sessions and evidence-based resources for ongoing learning.
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.
TeleECHO Clinics
Check out our TeleECHO Clinics on team-based care and collaboration planned for this spring and summer (more details coming soon):
Respecting and Valuing Diverse Perspectives in Shared Decision-Making
Integrated Practice Domain: Shared Decision Making and Communication
Competency: Collaboration- Respecting and valuing diverse perspectives
Explore how person- and family-centred approaches to care can transform clinical decision-making. This session highlights the use of evidence-based tools and decision aids to support shared decision-making, ensuring that the voices of individuals with dementia and their caregivers remain central throughout the care planning process.
Collaborative Care Planning for Behavioral Symptoms in Dementia
Integrated Practice Domain: Collaborative Care Planning
Competency: Collaboration: Engaging with patients, families, and caregivers in care planning
When behavioral symptoms challenge care delivery, coordinated team approaches are essential. This session focuses on how to navigate interdisciplinary planning, escalate complex cases when needed, and have effective, empathetic conversations with families during difficult transitions.
Past TeleECHO Clinics
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.
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.
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.
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.
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.
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.
This post is also available in: French