Building a Learning Community to Improve Dementia Care Transitions

Building a Learning Community to Improve Dementia Care Transitions

About

People with dementia face significant challenges when transitioning into long-term care, leading to distress for patients and families and inefficiencies in the healthcare system. Our project, Learning Together for Better Care, is focused on transforming care transitions for people living with dementia and others moving into long-term care at Vancouver Coastal Health (VCH) through a Learning Community, which is a collaborative space in Learning Health Systems (LHS), where healthcare providers, researchers, patients, and decision-makers work together to generate, share, and apply evidence-based knowledge in real-time to effectively foster continuous learning, data-driven decision-making, and co-designed solutions to enhance the quality of care, support for staff, and system efficiency.

Who’s Involved?



This project is led by Vancouver Coastal Health and UBC, with a multidisciplinary team of healthcare professionals, researchers, dementia care experts, patient and family partners, and decision-makers.

Core participants include:

  • Healthcare providers (nurses, physicians, care aides)
  • Researchers & data analysts
  • Patients & family caregivers
  • Health policy decision-makers

We use an inclusive, patient-oriented research model to ensure that all voices—especially those of patients and families—shape the development of better care solutions.

Project Goals

  • Improve care transitions for people with dementia through a Learning Community within a Learning Health Systems

  • Support Staff with Evidence-Based Practices – Equip long-term care workers with effective, practical solutions.

  • Reduce Health System Strain – Minimize hospital readmissions, decrease unnecessary antipsychotic use, and improve staff retention.

  • Foster Equity, Diversity & Inclusion (EDI) – Address systemic barriers and ensure diverse perspectives shape care practices.

    • What is a Learning Health System?

    An LHS is a health system that has the capacity to learn by bringing evidence to action, ensuring that real-world challenges lead to immediate improvements in the quality of care.


    In a high-performing LHS, learning takes place through cycles of:
  • Practice to Data – capturing data on clinical experience and health care delivery.

  • Data to Knowledge – analyzing qualitative and quantitative data to identify opportunities for improvement.

  • Knowledge to Practice: – applying insights through implementing evidence through training, and changes to policies and processes.

    • Through these learning cycles, sustainable and adaptive care models develop that benefits patients, families, and care providers alike.

    Anticipated Outcomes & Impact


    • Enhanced quality of life for dementia patients transitioning to long-term care.
    • Greater adoption of evidence-based care practices among healthcare providers.
    • Stronger workforce retention & support, reducing staff burnout.
    • Lower healthcare costs by reducing preventable hospital readmissions and medication overuse.
    • Scalability & replication – A blueprint for expanding the LHS model to other healthcare settings.
    • Foster Equity, Diversity & Inlusion (EDI) – Address Systemic barrier and ensure diverse perspectives shape care practices.

    This project represents a new era in dementia care—one where collaboration, learning, and evidence-based decision-making drive meaningful and lasting improvements.

    The Team


    Project co-Leads: Hung, L.(UBC) and Vasarhelyi, K.(VCH)

    Vancouver Coastal Health: Lee, M. Yanki, T. Agudo, J. Garcia, K. Villaos, V. Macfarlane, A. Benning, L. Jordan, S. Stockman, L. O’Neil, R. MacGowan, N. Gordon, M. Yousefi, V.

    The University of British Columbia: Wong, K. Lin, M. Mann, J. Berndt, A. Jackson, L. Chakraborty, N. Ren, L. Phinney, A.

    Simon Fraser University: Rutherford, A. Chiu, J. Moeini, M.

    McMaster University: Yous, M.

    Western University Canada: Connelly, D.

    Alzheimer Society British Columbia: Wu, S.
    Project Coordinator: Tang, Shereen

    Accomplishments

    Our poster presentations on Building a Learning Community to Improve Dementia Care Transitions at PATHS to a Cure 2025!

    Partners