‘Roadmap’ empowers care providers, families to reduce hospital transfer trauma

By Mari-Len De Guzman

Preventable transfers of dementia patients from long-term-care (LTC) facilities to emergency departments (ED) do more than just drain hospital resources; they inflict a hidden, lasting trauma on the very residents the system aims to protect.

Now, new data from the Chilliwack Division of Family Practice shows that arming long-term-care providers and staff with the right clinical tools could be the key to breaking this cycle. These tools are helping LTC care teams transition from reactive response to a proactive, person-centred approach with dementia patients.

Launched in September 2025, Chilliwack Division’s “Dementia Roadmap” project provides standardized dementia education and practice toolkit to all LTC facilities across Hope, Agassiz and Chilliwack. The initiative aims to integrate practical dementia tools and resources — including the P.I.E.C.E.S. framework, a 72-hour post-ED transfer case review, dementia care response checklist, and a clear escalation workflow — directly into the point of care and routine workflows.

“This project was tasked to educate care staff to know how to manage the behaviours of dementia patients in the care facility without having to transfer them to a hospital,” says Dr. Abimbola Dada, lead physician for the Dementia Roadmap project and a primary care doctor at Cedar Family Practice in Chilliwack.

Dr. Dada during a staff training at a facility in Agassiz

​Results to date have been promising: frontline staff reported a 58 per cent increase in confidence when using structured assessment templates. The positive responses show that when teams are empowered with the right roadmap, they can prioritize resident comfort and stability over unnecessary hospitalization.

Hospitals are very busy and can often leave dementia patients feeling distressed and confused. “We know that there is no cure for dementia and our focus, basically, is end-of-life comfort care,” Dada says. “In the end, the benefits (of hospital transfer) do not outweigh the risks for dementia patients.”

Increasing confidence in care providers to manage and care for dementia patients helps reduce the amount of unnecessary hospital transfers, especially for end-stage dementia, she adds.

According to data from the Alzheimer Society, an estimated 771,939 people in Canada are living with dementia. More than 414 people develop dementia on a daily basis — that’s more than 17 people every hour. Researchers estimate that by 2030, one million people in Canada will be living with dementia, with the number rising to 1.7 million by 2050.

The Dementia Roadmap is based on the Dementia Care Guidelines and Dementia Trajectory developed by Dr. Trevor Janz, medical director for long-term care with Interior Health East in Nelson, B.C.

Building confidence in care

The first six months of the Dementia Roadmap have yielded significant measurable improvements in how LTC teams approach resident care. An analysis of data collected from participants showed the most compelling shift occurred in the clinical decision-making process.

Key highlights from the results include:

Informed decision-making: Staff reported a 58 per cent increase in confidence when applying the “3-question template,” a tool used to determine if a change in a resident’s behavior can be managed safely on-site or requires a transfer.

Proactive interventions: A 51 per cent increase in confidence in suggesting appropriate interventions and interactions.

Holistic assessment: 43 per cent jump in overall confidence in using the P.I.E.C.E.S. (physical, intellectual, emotional, capabilities, environment, social)  framework to assess resident behavior, while comfort with cognitive screening tools like CAM and Mini-Cog increased by nearly 42 per cent.

Beyond the numbers, the qualitative feedback from frontline staff paints a picture of a transitioning care paradigm.

Participants noted the training helped them recognize “inappropriate transfers” and emphasized the importance of understanding a resident’s “baseline” to identify natural stages of dementia versus acute medical crises.

As one participant shared: “The most helpful part of the training was learning practical, person-centred strategies for communicating with and supporting individuals living with dementia, especially understanding behaviours as forms of communication.”

Another noted the program’s impact on clinical clarity and understanding “how to go step-by-step and identify who can and who should not go to the hospital.”

Empowering families

Chilliwack’s dementia program involves a dual-track strategy, with the second half of the program providing a roadmap for families. It involves training and educating resident family members about the dementia trajectory, ensuring they are on the same page when it comes to care planning and decision-making.

“Dementia can also cause behavioral changes — a lot of anxiety and anger towards themselves or towards their family,” says Dada. “Educating the family on what to expect would avoid confusion, so they know this is not the person being mean, this is the disease. And so they have more empathy.”

It also enables family members to catch signs of progression and know when and where to go for help when the time comes that their loved one will require long-term care.

The roadmap for families includes standardized caregiver information sheets and guides, which are incorporated into routine workflows, such as during initial intakes and family meetings. This ensures that expectations are aligned between families and practitioners at the point of care.

When family members understand the natural progression of the disease, the pressure for an emergency transfer is replaced by a common focus on the resident’s dignity, stability and compassionate end-of-life care.

Next steps

This year, project proponents are developing a train-the-trainer program with the goal of enabling between two and three “champions” at any given LTC facility to deliver and sustain the education program within their site.

The goal is to move away from external training resources, and have the internal champions lead the delivery of the dementia roadmap and mentor their peers.

To further empower the facilities to be self-sustaining, the program now intends to integrate the roadmap into standard workflows. This includes incorporating the 72-hour post-transfer case reviews, after a resident returns from the hospital, into routine processes. The dementia care response checklist will also be standardized and will be available for use at the point of care for all behavioral assessments.

Dada says it’s also important to remind families that there are a variety of resources they can access to educate themselves about dementia.

“It doesn’t stop the disease from progressing, but we can certainly make the journey more bearable and less distressing for the patient and their family.”

The Dementia Roadmap is one of many initiatives by the Chilliwack Division of Family Practice that reinforces its mission of partnering with the primary care community to develop and deliver innovative programs and initiatives that advance patient care and professional satisfaction.

Dementia-related resources and information:

Dementia Roadmap for Families
What to Expect After a Diagnosis of Dementia: An Indigenous Persons’ Guide
Alzheimer Society of Canada 
Dementia Awareness Resources Toolkit
Dementia Conversation Guide
What to Expect – Alzheimer Society