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.
2026 Theme:
Integrated Palliative Approaches for People Living with Serious Illness and Complex Chronic Conditions
This year’s Project ECHO Integrated Seniors’ Care series will explore how interdisciplinary teams can strengthen integrated palliative approaches across the continuum of care, including home care, primary care, community services, acute care, hospice, and long-term care settings. Aligned with the Canadian Interdisciplinary Palliative Care Competency Framework, the series will emphasize key competencies for high-quality palliative care across disciplines, including communication, symptom management, collaborative care planning, caregiver support, cultural safety, ethical practice, and workforce well-being. Through expert-led presentations, interdisciplinary panels, and case-based discussion, participants will explore practical, team-based approaches to earlier identification of palliative needs and coordinated, person- and family-centred care across the illness journey.
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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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Integrating a Palliative Approach Earlier: A Team-Based Approach for Complex Chronic Conditions
June 24, 2026 | 12–1pm Eastern (confirm time in local area)
An integrated palliative approach to care supports people living with serious chronic and life-limiting conditions by introducing palliative principles earlier in the illness trajectory, alongside ongoing treatment, and across care settings. This approach focuses on proactive, coordinated care that evolves with a person’s needs, while supporting quality of life, communication, and care that reflects the values and goals of individuals and families. This TeleECHO Clinic explores how interdisciplinary teams can apply a palliative approach earlier in the illness trajectory to anticipate and respond to changing symptoms, functional decline, caregiver needs, and goals of care. The session will also address common misconceptions about palliative care and highlight how shared understanding across care teams can support more person- and family-centred care.
Subject Matter Expert
Cheryl Spencer
Interim Chief Executive Officer
Canadian Hospice Palliative Care Association
Panelists:
Hsien Seow PhD,
Professor, Department of Oncology,
McMaster University
Shannon Reimer, RN BScN CHPCN© (she, her)
Palliative Care Coordinator
Southern Health
Regional Palliative Care Program
1 Mainpro+® Certified Activity credit
*This session is offered in English, with multilingual captioning available.
Caring for Others, Sustaining Ourselves: Self-Care in Integrated Palliative Care
July 15, 2026 | 12–1pm Eastern (confirm time in local area)
Supporting people living with serious illness and complex chronic conditions can be deeply meaningful work, but it also carries significant emotional and psychological demands for health care professionals across care settings. This TeleECHO Clinic explores self-care as an essential competency within integrated palliative care. Participants will examine the emotional impact of this work, including stress, compassion fatigue, and moral distress, and how these experiences can affect care across disciplines and settings. The session will also explore strategies to support individual and team resilience, while considering how teams and organizations can foster supportive cultures that sustain well-being and compassionate, person-centred care.
Subject Matter Expert
Nadine Valk
Coach, Educator, Facilitator and Systems-Level Change Leader
Panelists : To be confirmed
1 Mainpro+® Certified Activity credit
*This session is offered in English, with multilingual captioning available.
Past TeleECHO Clinics
Applying the Comprehensive Geriatric Assessment in Integrated, Team-Based Care
April 29, 2026
Dr. George Heckman emphasized that comprehensive geriatric assessment supports integrated, person-centred care by identifying medical, functional, cognitive, social, and caregiver risks before hospitalization. He highlighted shared data, narrative understanding, coordinated planning, teamwork, community supports, and accountability to reduce emergency visits, hospitalizations, and institutional care. Dr. Grace Park and Laura Harrison emphasized holistic care addressing safety, caregiver stress, goals, and follow-up.
Assessing and Addressing Caregiver Needs in Complex Care
April 1, 2026
Dr. Allison Williams outlined impact of caregiving on mental health, work, and social life, and introduced the Zarit Burden Inventory as a practical tool for recognizing and tracking burden. In panel discussion, Claire Webster emphasized education, navigation, and anger as key issues for caregivers, while Anna Malfara stressed trust, consistent follow-up, and coordinated home care support across care settings overall.
Respecting Spirituality and Cultural Identity in Integrated Seniors Care
March 4, 2026
Simon Lasair explains the importance of integrating spirituality into healthcare. Emphasizing differences between spiritual care generalists and specialists and the HOPE and FICA screening tools were introduced to help clinicians identify spiritual needs, support holistic care, and guide appropriate interdisciplinary referrals. Panelists Dr. Alexander Watts, Carly McPhee and Cindy Dwyer stress early spiritual conversations, explaining purpose, respecting reluctance, integrating beliefs into care planning, and team communication.
Assessing Frailty in Medically Complex Older Adults: Integrated Approaches to Care Across Home, Community, and Primary Care Settings
January 21, 2026
Dr. Kenneth Rockwood challenges clinicians to rethink frailty as more than a score, demonstrating how functional change and clinical judgment—supported by the Pictorial Fit Frail Scale – can sharpen assessment and care planning. Dr. Sabeen Ehsan builds on this foundation, showing how frailty pathways turn identification into action, enabling earlier intervention, clearer decision-making, and coordinated care across primary, home, community, and specialized services.
Navigating Autonomy and Safety in Complex Care
December 10, 2025
Dr. Kerry Bowman highlighted the need to balance autonomy, safety, and risk in community care, noting that individuals’ rights guide decision-making. He emphasized fluctuating capacity, cultural perspectives, and communication needs, encouraging clear assessment, open dialogue, and collaborative responses to complex situations that support client preferences and team safety. Olesya Kochetkova and Jean Johnston-McKitterick stressed respectful communication, documentation, family involvement, and coordinated supports.
Strengthening Integrated Care Planning with interRAI-HC and CAPs
December 3, 2025
Dr. John Hirdes highlighted how interRAI-HC data identifies risks, guides care planning, and tracks needs over time, using CAPs and predictive tools to strengthen integrated, person-centred, multidisciplinary care. Katarina Busija and Leslie Eckel emphasized that interRAI-HC and CAPs offer a shared language to identify risks, guide restorative interventions, address caregiver burden, and coordinate personalized, effective integrated care across settings.
Coordinating Transitions in Complex Dementia and Multimorbidity Cases
November 26, 2025
Dr. Ivy Oandasan highlighted systemic barriers—siloed care, limited primary care capacity, and weak interprofessional coordination—calling for integrated, team-based primary care grounded in the four C’s. Carin Ann MacInroy illustrated the human impact through her caregiver experience, revealing overwhelming cognitive load caused by fragmented systems. Amanda Garrets added to a panel discussion that emphasized proactive planning, clear accountability, shared information, and technology-enabled coordination to improve transitions.
Strengthening Team Communication Through Role Clarity
October 1, 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 presented by the Canadian Home Care Association with support from the Canadian Medical Association.
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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.
General Inquiries: chca@cdnhomecare.ca
Membership Inquiries: membership@cdnhomecare.ca
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