the rising prevalence of alzheimer s disease and related dementias ( henceforth referred to as dementia ) is emerging as a leading global health system challenge . effective early diagnosis and management models are required to mitigate its impact on patients , caregivers , and health - care systems . enhancing primary care capacity however , dementia care predominantly resides with geriatric specialists , who are in short supply in canada and elsewhere , delaying access to care . to enhance the care of persons with dementia , many of these have been established as primary care - based memory clinics ( pcmcs ) . initial evaluations suggest that pcmcs can provide timelier assessment , lead to a high degree of satisfaction among referring physicians , patients , and caregivers , and streamline access to specialists . in order to retain the fidelity of such programs and consistency with initial training and practice guidelines , and practice drift and ensure ongoing high quality of care , quality assurance frameworks are needed . quality indicators ( qis ) , based on best practices , define achievable benchmarks and a quality assurance framework facilitates practice improvement through targeted , educational quality improvement mechanisms . to our knowledge , there is no quality assurance framework specific to dementia care in primary care - based settings . this paper describes the results of a consensus approach to identify qis and quality improvement mechanisms in an ontario - wide network of interprofessional pcmcs , and identify potential barriers and facilitators to the implementation of a quality assurance framework . a delphi technique was deployed to obtain agreement from pcmc clinicians and dementia specialists on preferred qis and quality improvement mechanisms . the delphi technique is an iterative consensus process , wherein surveys are used to solicit opinions from groups , and responses summarized and redistributed in a subsequent round for consideration . we identified 38 candidate qis and quality improvement mechanisms for dementia care by reviewing existing clinical guidelines and quality indicator and improvement compendiums developed with standardized methods ( table 1 ) . respondents were asked to rate the qis and quality improvement mechanisms using a continuous integer 9-point scale , with 1 representing the least important and 9 the most important . links to the web - based survey were electronically distributed to all pcmc clinicians ( n = 283 ) and ontario specialists through the ontario medical association sections of geriatric medicine ( n = 123 ) and neurologists ( n = 134 ) , and the canadian association of geriatric psychiatrists ( n = 305 ) . after each round , qis and improvement measures in the lower two tertiles of agreement ( i.e. , with mean ratings less than 7 ) were excluded , and those remaining were reviewed by the authors guided by respondent comments . qis and quality improvement mechanisms deemed redundant or containing duplicate themes were combined or amended with attention to preserving their intent and conciseness . data from the preceding round , including number of respondents , rating means , and standard deviations , were included in the subsequent round . student s t - test was used to identify significant differences between pcmc clinicians and specialists . spss version 23.0 ( ibm corp . ) was used , with two - sided p values of < .05 as the threshold for statistical significance . two authors ( gh , vb ) independently analyzed all written comments using descriptive content analysis and incorporated the feedback into the presentation of qis and quality improvement mechanisms in the second delphi round . a delphi technique was deployed to obtain agreement from pcmc clinicians and dementia specialists on preferred qis and quality improvement mechanisms . the delphi technique is an iterative consensus process , wherein surveys are used to solicit opinions from groups , and responses summarized and redistributed in a subsequent round for consideration . we identified 38 candidate qis and quality improvement mechanisms for dementia care by reviewing existing clinical guidelines and quality indicator and improvement compendiums developed with standardized methods ( table 1 ) . respondents were asked to rate the qis and quality improvement mechanisms using a continuous integer 9-point scale , with 1 representing the least important and 9 the most important . links to the web - based survey were electronically distributed to all pcmc clinicians ( n = 283 ) and ontario specialists through the ontario medical association sections of geriatric medicine ( n = 123 ) and neurologists ( n = 134 ) , and the canadian association of geriatric psychiatrists ( n = 305 ) . after each round , qis and improvement measures in the lower two tertiles of agreement ( i.e. , with mean ratings less than 7 ) were excluded , and those remaining were reviewed by the authors guided by respondent comments . qis and quality improvement mechanisms deemed redundant or containing duplicate themes were combined or amended with attention to preserving their intent and conciseness . data from the preceding round , including number of respondents , rating means , and standard deviations , were included in the subsequent round . student s t - test was used to identify significant differences between pcmc clinicians and specialists . spss version 23.0 ( ibm corp . ) was used , with two - sided p values of < .05 as the threshold for statistical significance . two authors ( gh , vb ) independently analyzed all written comments using descriptive content analysis and incorporated the feedback into the presentation of qis and quality improvement mechanisms in the second delphi round . two survey rounds were conducted between april and june 2014 . in the first round , 842 surveys were distributed with a response rate of 21.3% . the majority of respondents were physicians , and nurses and other health professionals equally represented the remainder of respondents ( table 2 ) . respondents had an average of 14.6  10.1 years of clinical practice with older adults . among pcmc respondents , 31% were from urban centres , 42% rural settings , and 25% from mixed urban / rural populations . in contrast , 73% of specialists worked in urban settings , and 24% served mixed populations . only 11 neurologists responded to the first survey , and their specialty was not included in round 2 . in round 2 , respondents had an average of 17.42  10.08 years of clinical practice with older adults and practice settings were similar to round 1 . a third delphi round was not conducted due to the substantial drop in response rate between rounds 1 and 2 . table 3 presents the results of the consensus process and table 4 presents the final list of quality indicators . quality improvement mechanisms characterized by specialist integration , including case discussions , shared care , observerships , and mentorships , ranked highly ( table 5 ) . other preferred quality improvement mechanisms included standardized electronic charting forms , self - directed learning activities , and interactive programs . survey respondents recommended that between 1030% of patients seen in a pcmc also be reviewed by a specialist . descriptive content analysis identified three themes related to potential barriers and facilitators to the establishment of a quality assurance framework in pcmcs : 1 ) its perceived importance , 2 ) collaboration and role clarity , and 3 ) the implementation process . almost all respondents mentioned the need to maintain high - quality care through ongoing , targeted training on pertinent clinical knowledge and consistency of approach among pcmc teams . most recognized a formal quality assurance framework and individual qis as essential .  great indicators and very necessary  [ pcmc clinician , round 1 ] . our challenge is to maintain evidence based salience , which ultimately facilitates improved quality of life for persons with dementia and their family  [ pcmc clinician , delphi round 2 ] . all are relevant quality indicators for a pcmc  [ specialist , round 2 ] . however , a few respondents were unsure why a quality assurance framework was needed at all . others seemed unfamiliar with the purpose of quality assurance and construed the idea of tracking qis as supplemental work . is the intent of the questions to assess what we are doing now or [ what ] we think should be the standard ?  [ pcmc clinician , round 1 ] . this is the canadian consensus guideline that every doc should know  [ specialist , round 1 ; emphasis added by authors ] . a second theme pertained to the operationalization and implementation of the quality assurance framework within the context of pcmcs , and identified a lack of clearly delineated responsibilities among referring clinicians , pcmcs , and specialists . respondents perceived this as problematic because absence of clarity impedes the capture of clinical documentation relevant to qi measurement . information is sent back to referral physician with recommendations for caregiver and patient mostly related to change in medication or treatment , lifestyle modification and support resources  [ pcmc clinician , round 2 ] . this lack of clarity was considered most problematic with regard to patient follow - up . patients with dementia with great plans should not need constant surveillance and follow up but ... this is not my experience ... they appear to often benefit from a watchdog team to ensure their decisions are being carried out .  [ specialist , round 1 ] . similar concerns were raised regarding the management of comorbidities .   [ my ] assumption is that management of comorbidities is the primary care physician s domain . recommendations are made for lifestyle changes , however [ congestive heart failure ] and diabetes management are only commented on , suggestions are made to the referring physician  [ pcmc clinician , round 2 ] . it was not clear which health care provider should conduct a physical examination , leading to gaps in assessment .  referring family physicians are expected to have completed a complete physical including appropriate neuro exam prior to referral  [ pcmc clinician , round 1 ] . my biggest concern is that the pcmc team assumes that a proper physical and neurologic exam has been done by the referring source  [ specialist , round 1 ] . respondents provided several comments on potential barriers to the implementation process of a quality assurance framework in pcmcs . one of the main obstacles was the perceived burden of documentation required to implement qis . [ it will take a lot of work to do the ] searching and documenting as a group of patients needs a process to set up how to search , then doing the search  [ pcmc clinician , round 2 ] . integrating qis into existing electronic medical records was touted as a solution , though potentially a resource - intensive one . making up stamps to collect this information is doable but takes time for someone to make the [ standardized template ] and then to test it a second issue identified in relation to the implementation of the quality assurance framework is the need to establish benchmarks to properly interpret qi scores . i think one of the most important quality indicators is a comparison of the pcmc performance versus the specialist , done on both patients referred to the specialist by the pcmc , and unselected patients seen in the clinic that would not have been referred to the specialist  [ specialist , round 1 ] . access to other health care professionals , within pcmcs and in the community , was identified as important for quality care , though access was not perceived as uniform .  having a pharmacist on our team is a great asset .... the local [ pharmacists ] volunteer their time to assist us at our once monthly day long clinics  [ pcmc clinician , round 2 ] . the [ social work ] and [ occupational therapy ] members of the team do an excellent job  the [ alzheimer s society ] representative has been excellent as well when given an opportunity  [ pcmc clinician , round 2 ] . an important finding is the relative lack of importance ascribed to end - of - life planning . while respondents agreed on its importance , many expressed that such planning discussions were not appropriate for patients with less advanced disease . palliation and end of life discussion is usually not appropriate at time of our memory clinic initial or follow - up assessment since our patients are not that advanced . family physician team will do this in following up patient  [ pcmc clinician , round 1 ] . lastly , many respondents expressed a preference for quality improvement mechanisms and learning opportunities characterized by active engagement . they also identified specialists as agents to promote care quality , particularly in the context of a shared care approach . this [ case review ] could be done at the same time , as the specialist mentoring the clinic is in a clinic day with the team  [ pcmc clinician , round 1 ] . barriers to the implementation of this framework included role confusion among stakeholders and limited resources . descriptive content analysis identified three themes related to potential barriers and facilitators to the establishment of a quality assurance framework in pcmcs : 1 ) its perceived importance , 2 ) collaboration and role clarity , and 3 ) the implementation process . almost all respondents mentioned the need to maintain high - quality care through ongoing , targeted training on pertinent clinical knowledge and consistency of approach among pcmc teams . most recognized a formal quality assurance framework and individual qis as essential .  great indicators and very necessary  [ pcmc clinician , round 1 ] . our challenge is to maintain evidence based salience , which ultimately facilitates improved quality of life for persons with dementia and their family  [ pcmc clinician , delphi round 2 ] . all are relevant quality indicators for a pcmc  [ specialist , round 2 ] . however , a few respondents were unsure why a quality assurance framework was needed at all . others seemed unfamiliar with the purpose of quality assurance and construed the idea of tracking qis as supplemental work . is the intent of the questions to assess what we are doing now or [ what ] we think should be the standard ?  [ pcmc clinician , round 1 ] . this is the canadian consensus guideline that every doc should know  [ specialist , round 1 ; emphasis added by authors ] . a second theme pertained to the operationalization and implementation of the quality assurance framework within the context of pcmcs , and identified a lack of clearly delineated responsibilities among referring clinicians , pcmcs , and specialists . respondents perceived this as problematic because absence of clarity impedes the capture of clinical documentation relevant to qi measurement . information is sent back to referral physician with recommendations for caregiver and patient mostly related to change in medication or treatment , lifestyle modification and support resources  [ pcmc clinician , round 2 ] . this lack of clarity was considered most problematic with regard to patient follow - up . patients with dementia with great plans should not need constant surveillance and follow up but ... this is not my experience ... they appear to often benefit from a watchdog team to ensure their decisions are being carried out .  [ specialist , round 1 ] . similar concerns were raised regarding the management of comorbidities .   [ my ] assumption is that management of comorbidities is the primary care physician s domain . recommendations are made for lifestyle changes , however [ congestive heart failure ] and diabetes management are only commented on , suggestions are made to the referring physician  [ pcmc clinician , round 2 ] . it was not clear which health care provider should conduct a physical examination , leading to gaps in assessment .  referring family physicians are expected to have completed a complete physical including appropriate neuro exam prior to referral  [ pcmc clinician , round 1 ] . my biggest concern is that the pcmc team assumes that a proper physical and neurologic exam has been done by the referring source  [ specialist , round 1 ] . respondents provided several comments on potential barriers to the implementation process of a quality assurance framework in pcmcs . one of the main obstacles was the perceived burden of documentation required to implement qis . [ it will take a lot of work to do the ] searching and documenting as a group of patients needs a process to set up how to search , then doing the search  [ pcmc clinician , round 2 ] . integrating qis into existing electronic medical records was touted as a solution , though potentially a resource - intensive one . making up stamps to collect this information is doable but takes time for someone to make the [ standardized template ] and then to test it  [ pcmc clinician , round 2 ] . a second issue identified in relation to the implementation of the quality assurance framework i think one of the most important quality indicators is a comparison of the pcmc performance versus the specialist , done on both patients referred to the specialist by the pcmc , and unselected patients seen in the clinic that would not have been referred to the specialist access to other health care professionals , within pcmcs and in the community , was identified as important for quality care , though access was not perceived as uniform .  having a pharmacist on our team is a great asset .... the local [ pharmacists ] volunteer their time to assist us at our once monthly day long clinics  [ pcmc clinician , round 2 ] . the [ social work ] and [ occupational therapy ] members of the team do an excellent job  the [ alzheimer s society ] representative has been excellent as well when given an opportunity  [ pcmc clinician , round 2 ] . an important finding is the relative lack of importance ascribed to end - of - life planning . while respondents agreed on its importance , many expressed that such planning discussions were not appropriate for patients with less advanced disease . palliation and end of life discussion is usually not appropriate at time of our memory clinic initial or follow - up assessment since our patients are not that advanced . family physician team will do this in following up patient  [ pcmc clinician , round 1 ] . lastly , many respondents expressed a preference for quality improvement mechanisms and learning opportunities characterized by active engagement . they also identified specialists as agents to promote care quality , particularly in the context of a shared care approach . this [ case review ] could be done at the same time , as the specialist mentoring the clinic is in a clinic day with the team  [ pcmc clinician , round 1 ] . barriers to the implementation of this framework included role confusion among stakeholders and limited resources . almost all respondents mentioned the need to maintain high - quality care through ongoing , targeted training on pertinent clinical knowledge and consistency of approach among pcmc teams . most recognized a formal quality assurance framework and individual qis as essential .  great indicators and very necessary  [ pcmc clinician , round 1 ] . our challenge is to maintain evidence based salience , which ultimately facilitates improved quality of life for persons with dementia and their family  [ pcmc clinician , delphi round 2 ] . all are relevant quality indicators for a pcmc  [ specialist , round 2 ] . however , a few respondents were unsure why a quality assurance framework was needed at all . others seemed unfamiliar with the purpose of quality assurance and construed the idea of tracking qis as supplemental work . is the intent of the questions to assess what we are doing now or [ what ] we think should be the standard ?  [ pcmc clinician , round 1 ] . this is the canadian consensus guideline that every doc should know  [ specialist , round 1 ; emphasis added by authors ] . a second theme pertained to the operationalization and implementation of the quality assurance framework within the context of pcmcs , and identified a lack of clearly delineated responsibilities among referring clinicians , pcmcs , and specialists . respondents perceived this as problematic because absence of clarity impedes the capture of clinical documentation relevant to qi measurement . information is sent back to referral physician with recommendations for caregiver and patient mostly related to change in medication or treatment , lifestyle modification and support resources  [ pcmc clinician , round 2 ] . this lack of clarity was considered most problematic with regard to patient follow - up . patients with dementia with great plans should not need constant surveillance and follow up but ... this is not my experience ... they appear to often benefit from a watchdog team to ensure their decisions are being carried out .  [ specialist , round 1 ] . similar concerns were raised regarding the management of comorbidities .   [ my ] assumption is that management of comorbidities is the primary care physician s domain . recommendations are made for lifestyle changes , however [ congestive heart failure ] and diabetes management are only commented on , suggestions are made to the referring physician  [ pcmc clinician , round 2 ] . it was not clear which health care provider should conduct a physical examination , leading to gaps in assessment . referring family physicians are expected to have completed a complete physical including appropriate neuro exam prior to referral  [ pcmc clinician , round 1 ] . my biggest concern is that the pcmc team assumes that a proper physical and neurologic exam has been done by the referring source  [ specialist , round 1 ] . respondents provided several comments on potential barriers to the implementation process of a quality assurance framework in pcmcs . one of the main obstacles was the perceived burden of documentation required to implement qis . [ it will take a lot of work to do the ] searching and documenting as a group of patients needs a process to set up how to search , then doing the search  [ pcmc clinician , round 2 ] . integrating qis into existing electronic medical records was touted as a solution , though potentially a resource - intensive one . making up stamps to collect this information is doable but takes time for someone to make the [ standardized template ] and then to test it a second issue identified in relation to the implementation of the quality assurance framework is the need to establish benchmarks to properly interpret qi scores . i think one of the most important quality indicators is a comparison of the pcmc performance versus the specialist , done on both patients referred to the specialist by the pcmc , and unselected patients seen in the clinic that would not have been referred to the specialist  [ specialist , round 1 ] . access to other health care professionals , within pcmcs and in the community , was identified as important for quality care , though access was not perceived as uniform . having a pharmacist on our team is a great asset .... the local [ pharmacists ] volunteer their time to assist us at our once monthly day long clinics  [ pcmc clinician , round 2 ] . the [ social work ] and [ occupational therapy ] members of the team do an excellent job  the [ alzheimer s society ] representative has been excellent as well when given an opportunity  [ pcmc clinician , round 2 ] . an important finding is the relative lack of importance ascribed to end - of - life planning . while respondents agreed on its importance , many expressed that such planning discussions were not appropriate for patients with less advanced disease .  palliation and end of life discussion is usually not appropriate at time of our memory clinic initial or follow - up assessment since our patients are not that advanced . family physician team will do this in following up patient  [ pcmc clinician , round 1 ] . lastly , many respondents expressed a preference for quality improvement mechanisms and learning opportunities characterized by active engagement . they also identified specialists as agents to promote care quality , particularly in the context of a shared care approach . this [ case review ] could be done at the same time , as the specialist mentoring the clinic is in a clinic day with the team  [ pcmc clinician , round 1 ] . barriers to the implementation of this framework included role confusion among stakeholders and limited resources . this study used a consultative process among primary and specialty providers to identify a core group of qis and preferred quality improvement mechanisms for dementia care . quality assurance can be an effective method to ensure fidelity to best practices and maintain a high standard of care quality . selected qis address care processes , assessment and reassessment , medication review and management , investigations , non - pharmacological management , pharmacological management , and managing concomitant conditions . selected quality improvement mechanisms emphasize a desire for multimodal education and closer collaboration with specialists . assessing care quality and publically reporting the findings are increasingly commonplace . however , quality assurance still mainly focuses on specific care sectors or episodes , rather than on overall care for conditions that require coordination and collaboration across multiple sectors . in that context critical considerations include educating clinicians about the role of quality assurance , improving role clarity among providers involved in dementia care , expanding access to allied health professionals , and creating standardized electronic medical record templates to simplify qi documentation . quality assurance must not create additional burden on clinicians often working with limited resources and time , a burden that could also impact the quality of the clinician - patient interaction . respondents proposed that 1030% of patients seen in pcmcs be reviewed with a specialist , preferably in a shared care approach . closer integration of urban specialists with rural pcmcs represents a tremendous opportunity to extend quality dementia care , particularly to rural patients . , it will be necessary to identify barriers ( e.g. , allocation of funding ) and facilitators ( e.g. , resources for coordination , electronic medical records , telemedicine ) . another important finding was the relatively low rankings of qis related to end - of - life planning with dementia patients . in addition to potential discomfort among clinicians to address such issues , this finding may also stem from the understandable desire to maintain hope and engagement early in the course of the illness , though undue delays may leave patients and caregivers less able to meaningfully participate in such discussions . the most important identified barrier to the implementation of the quality assurance framework is the need for greater clarity on responsibilities of referring family physicians , pcmc clinicians , and specialists , particularly with respect to follow - up , physical examination , and care of complex comorbidities . quality assurance often targets relatively simple conditions , such as hypertension , or restricts its scope to specific aspects , processes or locations of care . in contrast , dementia , like all major chronic conditions , follows a course of progressive decline punctuated by increasingly frequent health complications ( related to dementia itself , as well as to exacerbations of concurrent comorbidities ) , multiple care transitions , progressive caregiver stress and health service utilization , and ultimately death . optimal dementia care thus requires a systems approach of integration and coordination . addressing greater role clarity among all dementia stakeholders , a task that with proper resources could be coordinated from within pcmcs , requires immediate attention , in order to ensure a stable clinical infrastructure that is able to safely and effectively address the needs of these patients , wherever they may be and whenever they arise . until such integration is achieved first , only two delphi rounds were conducted because the response rate fell markedly after the first . however , the response rate remained above what is considered appropriate for delphi surveys , and ratings of individual qis , except those related to physical examination , remained stable between rounds . a second limitation is that the survey was solely distributed within the previously described network of pcmcs , though this model is widely implemented across ontario . as the qis were selected by both primary and specialist providers , they are likely applicable to other dementia care settings . third , participation of neurologists in the first round was low and their response was not solicited in the second round . the relatively lower participation of neurologists in this work , compared to geriatricians and geriatric psychiatrists , is notable and requires further investigation . fourth , allied health providers were under - represented and , given their importance in dementia care , additional work is required to further understand and develop their role in an integrated system of dementia care . fifth , patient and caregivers were not surveyed regarding what they consider to be important qis . finally , candidate qis and quality improvement mechanisms were not identified through a systematic literature review , but the use of published guidelines and compendiums likely identified the most important elements of quality dementia care , which would thus have remained highly ranked . first , only two delphi rounds were conducted because the response rate fell markedly after the first . however , the response rate remained above what is considered appropriate for delphi surveys , and ratings of individual qis , except those related to physical examination , remained stable between rounds . a second limitation is that the survey was solely distributed within the previously described network of pcmcs , though this model is widely implemented across ontario . as the qis were selected by both primary and specialist providers , they are likely applicable to other dementia care settings . third , participation of neurologists in the first round was low and their response was not solicited in the second round . the relatively lower participation of neurologists in this work , compared to geriatricians and geriatric psychiatrists , is notable and requires further investigation . fourth , allied health providers were under - represented and , given their importance in dementia care , additional work is required to further understand and develop their role in an integrated system of dementia care . fifth , patient and caregivers were not surveyed regarding what they consider to be important qis . finally , candidate qis and quality improvement mechanisms were not identified through a systematic literature review , but the use of published guidelines and compendiums likely identified the most important elements of quality dementia care , which would thus have remained highly ranked . while this study has identified qis and quality improvement mechanisms to assess care quality for dementia , findings underscore the importance of system integration for the provision of quality dementia care , with specifically defined and mutually understood roles among stakeholders and , where necessary , the reallocation of existing resources to support this approach to care . an approach whereby clear roles are negotiated among dementia stakeholders can provide sufficient flexibility to meet regional needs ( especially in rural areas where access to specialists is more limited ) , foster more effective collaboration and accountability , and thus facilitate the delivery and measurement of care quality for dementia . within that context , proper field - testing , validation , and evaluation of selected qis and quality improvement mechanisms this work has significant implications on the organization of care for aging patients with complex conditions . primary and specialist providers share the responsibility of providing and supporting integrated dementia quality care . as such , the care of persons with cognitive impairment would be enhanced by the development of a practical and realistically feasible quality assurance framework , under whose umbrella both pcmc and specialist services are integrated , and which ensures high fidelity to intended design and best practices , and thus maintains a high level of care quality .
backgroundprimary care - based memory clinics ( pcmcs ) have been established in several jurisdictions to improve the care for persons with alzheimer s disease and related dementias . 
 we sought to identify key quality indicators ( qis ) , quality improvement mechanisms , and potential barriers and facilitators to the establishment of a quality assurance framework for pcmcs.methodswe employed a delphi approach to obtain consensus from pcmc clinicians and specialist physicians on qis and quality improvement mechanisms . 
 thirty - eight candidate qis and 19 potential quality improvement mechanisms were presented to participants in two rounds of electronic delphi surveys . 
 written comments were collected and descriptively analyzed.resultsthe response rate for the first and second rounds were 21.3% ( n = 179 ) and 12.8% ( n = 88 ) , respectively . 
 the majority of respondents were physicians . 
 fourteen qis remained after the consensus process . 
 ten quality improvement mechanisms were selected with those characterized by specialist integration , such as case discussions and mentorships , being ranked highly . 
 written comments revealed three major themes related to potential barriers and facilitators to quality assurance : 1 ) perceived importance , 2 ) collaboration and role clarity , and 3 ) implementation process.conclusionwe successfully utilized a consultative process among primary and specialty providers to identify core qis and quality improvement mechanisms for pcmcs . identified quality improvement mechanisms highlight desire for multi - modal education . system integration and closer integration between pcmcs and specialists were emphasized as essential for the provision of high - quality dementia care in community settings .