Provincial Approach & Progress

Connecting People & Community for Living Well



Visual summary showing major milestones and progress timeline. Additional details below.


Spread, Scale and Sustain Provincially

The 2023-2026 Health Canada grant will focus on five key activities centered around the Connecting People and Community for Living Well Model.

  • Spreading the model to new communities to support those living with dementia and carers
  • Scaling the model to support the wellbeing of other underserved populations
  • Sustaining the model in the five rural communities who were part of the 2020-2023 grant (Drumheller, Innisfail, Stony Plain, Three Hills, and Westlock)
  • Translating and disseminating knowledge, learnings, policy and infrastructure recommendations
  • Evaluating outcomes and impact, including social return on investment (SROI)

These activities will contribute further to the evidence base on how to build a system that supports people over their life course to live well in their own homes and communities.

Connecting People and Community for Living Well

Provincial team awarded a $1.4 million grant from Health Canada as part of the Health Canada Health Care Policy Contribution Program (HCPCP). The grant supported continuation of this work in five rural communities and the development of two main deliverables. These deliverables were informed by learnings from the applied research activities. See the Applied Research Summary and Summary of Lessons Learned.

  • Wellbeing Guide - Supports measurement and monitoring of actions taken at the local level by multi-sector community teams to build and sustain wellbeing. Over time, the guide will also help identify areas that are challenging to address locally and may require system or policy-level changes.
  • Competency Framework - Outlines the skill, knowledge and behaviors needed to advance collaborative multi-sector work in the community.

During this period, the Connecting People and Community for Living Well Model was created as well as an infographic of grant activities and impact.

Building on Learnings

Wellbeing was identified as key concept in supporting healthy ageing across the lifespan. The initiative was renamed to ‘Connecting People and Community for Living Well’ to reflect partnerships and the focus on learning how to better support those in the community to ‘live well.’

Teams identified a gap in understanding the skills, knowledge and supports needed to grow and sustain shared planning and implementation of needed supports.

During this phase, an economic analysis of the work was completed and demonstrated that for Alberta Health Services – for every $1 spent, there was a return on investment (ROI) of:

  • $1.26 in the one urban community
  • $6.79 in the five rural communities

Full report

Demonstration Phase (Primary Health Care Integrated Geriatric Services Initiative)

With the support of the provincial PHC IGSI team, five PCNs and their respective communities began working locally to:

  • Improve primary care clinic processes
  • Build relationships between health, social and community partners
  • Identify priority areas and develop a shared action plan based on local needs
  • Engage people living with dementia and carers in both provincial and local planning

The provincial team established a monthly virtual meeting to bring stakeholders together for networking, education and knowledge sharing. This group was instrumental in developing and delivering four education workshops.

Key learnings

Impact on individuals - People living with dementia and carers reported increased awareness of, and access to, supports and education resources available locally.

Community outcomes - Bolstering multi-sector relationships at the community level increased local capacity to meet the needs of the aging population through community coalition development, and action planning across health, social, community, municipal and public sectors.

Health system impact measures - Participating communities showed that for those with a diagnosis of dementia, there was a trend of decrease in:

  • unplanned emergency department visits, and
  • acute care length of stay (hospitals or urgent care centres)

View PHC IGSI final evaluation report (2019) | summary

Formalizing Goals and Approach

Grant funding through Alberta Health enabled launch of the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) and the provincial team. This work aligned with 2 of the 3 outcomes outlined in the Alberta Dementia Strategy and Action Plan (ADSAP).

The pilot/demonstration phase was built around the Anticipating the Future Framework and focused on advancing integration between health and social services at a community level. Its focus was to increase capacity of community teams to provide ongoing care and support for those living in their community affected by dementia. This included those with a diagnosis of dementia and their carers.

Activities included increasing knowledge of dementia, improving primary care clinic processes, efforts to understand local level supports available for those affected by dementia, identifying gaps, and joint action planning at a community level between health and social partners.

Stakeholder Engagement and Awareness Building

Stakeholder engagement involving care partners of people living with dementia.

  • Advancing Dementia Diagnosis and Management in Alberta Workshop, 2016
    Reviewed existing primary care models to support those 65 and older with dementia. Workshop participants were surveyed; see summary of key themes.
  • Care partners of those with dementia were consulted to understand the priorities they envisioned to enhance wellbeing and quality of life in community. This resulted in development of Messages from Dementia Care Partners, which created a foundation for further work.

Discovery and Data Collection

Environmental scan completed of geriatric services in Alberta’s Primary Care Networks (PCNs) completed by the Seniors Health Strategic Clinical Network. The scan revealed gaps in community services for people living with dementia and their carers.