Lessons Learned from Implementing Multi-Disciplinary Interprofessional Team (MINT) Memory Clinics in Social Housing

Background: The process of accessing diagnostic and care planning support in dementia care is made difficult by system fragmentation and long wait times for geriatric specialists. These challenges are even more prominent for low-income older adults who often face additional barriers to accessing health and social care. The North Toronto Neighbourhood Care Team has implemented Multi-Disciplinary Interprofessional Team (MINT) Memory clinics in four Toronto Seniors Housing Corporation buildings to support low income tenants in accessing dementia care where they live.

 

Approach: The North Toronto Neighbourhood Care Team collaborates with the Toronto Seniors Housing Corporation to bring together health and social service agencies, providing a unified approach to services for tenants as one cohesive team. The Toronto Seniors Housing Corporation supports 15,000 low income older adults with access to subsidized housing. Working in partnership with tenants with lived experience and tenant leaders, our team facilitated several tenant engagement and staff engagement opportunities to discuss the importance of early recognition and care planning for those with cognitive decline and to define and structure our approach to dementia care in four Toronto Seniors Housing buildings.

 

The MINT Memory clinic model was chosen as an equity-based, primary care model that relies on strong cross-organizational interprofessional teamwork to diagnose and care plan for tenants experiencing concerns with their cognition. Thirteen members of our North Toronto Neighbourhood Care Team across four organizations have received MINT Clinic training and have started regular Mint Memory clinics where tenants live. Comprehensive assessments take place in the tenant’s unit with collateral interviews by phone or in person with care partners simultaneously in a medical clinic room or other private space in the building. The team then collaborates and shares their findings with the physician who then speaks to the tenant and family member about the team’s recommendations.

 

Results: By leaning into tenant and staff engagement, the need for local, integrated, team based dementia care became clear. The Neighbourhood Care Team supports over 200 tenants in these buildings with 42 being identified as requiring or benefitting from immediate access to a MINT clinic. At present, our team has supported nine tenants who have accessed diagnostic support and clear care plans for managing their care in the community. These care plans are communicated within the tenant’s circle of care. Tenant, care partner and staff feedback have been overwhelmingly positive as we continue to adjust our model.

 

Implications: This new model of mobile dementia care demonstrates that to provide equitable access to care for the most vulnerable, cross-organizational partnership, integration, and care in the home are each necessary. Access to diagnostic and care planning in dementia care will continue to be critical to enable health care teams to deliver value concordant care. This type of care provided where people live will support people living at home for longer, an issue that is prominent for low-income seniors, many of whom have experienced being unhoused or precariously housed.