As Japan is aging rapidly with more people with dementia, healthcare providers need to develop and share the care delivery model in order to respond to the need of not only the patients' but also of the families' and society's. The authors have developed a disease management and care system of the people with dementia based on the previous model developed by us for other diseases. Through the case reviews of the patients, this model proved to be useful in visually describing the patients' courses. We are going to develop as a next step a model to foresee the patients' progress so that we may be able to make timely interventions. Additionally, we have a plan to use it to improve the Japanese guideline of dementia care.