Models of Care Toolkit

Integrated palliative care

patient in a hospital bed a nurse looking over herAn integrated care model involves palliative care from the time of a cancer diagnosis. It focuses on the importance of early referral to palliative care and educates patients that palliative care is part of the care they receive rather than a service to support end-of-life planning.

Key elements include:

  • Provider education and competency training
  • Symptom assessment tools and guidance on advanced care planning
  • Patient Reported Outcome measures to identify patients who would most benefit from early palliative integration

Outpatient palliative care improves symptom burden and quality of life and reduces unnecessary health care use in patients with cancer.

Primary care teams that are located in or easily accessible to communities play a major role in providing palliative care. Their broad knowledge, long-term patient relationships and ability to carry out home visits, as well as capacity to communicate and coordinate with other health-care resources, means primary care providers can address complex issues faced by patients.

Early integration of palliative care enables:

triangle visual

  • Informed decision-making by patients and their primary care teams
  • An enhanced feeling of engagement and ownership in care decision-making by patients and their families
  • Reduced re-admissions or unnecessary health care use at the end of life, decreasing overall healthcare expenditures and improving quality of life

Challenges faced by primary care providers when integrating palliative care include:

  • Acquisition of counselling skills
  • Lack of standard guidelines for medications
  • Keeping abreast with new knowledge
  • Lack of support from their team
  • Time constraints

Outcome indicators to evaluate the impact of an intervention in the palliative phase include patient experience measures and/or clinical measures.

This cross-jurisdiction program supports the early integration of palliative care initiatives in several jurisdictions including British Columbia, Ontario, Saskatchewan, Nova Scotia, Prince Edward Island, Newfoundland and Labrador, the Yukon and Northwest Territories. It includes three main components:

  • Inter-professional palliative care education that provides practical knowledge and skills to primary care and cancer care teams and supports a connected and collaborative approach to decision-making
  • Early identification of patients with palliative care needs through routine symptom screening, functional assessments and patient consultations
  • Planning and management activities including working with patients to incorporate goals of care and advanced care planning discussions and implementing routine symptom management and functional assessments.

Linkages to community, primary care and specialized palliative care enhance the value and impact of this approach.

Innovative programs developed in Ontario, Nova Scotia, Alberta and Prince Edward Island equip paramedics to deliver palliative care support to patients at home.

Working with Healthcare Excellence Canada, the Partnership helped to scale and spread this model to improve care across Canada. It includes three main components:

  • A clinical practice guideline or protocol specific to palliative care that allows paramedics to provide care in the home without transporting patients to the emergency department
  • Paramedic-specific education on palliative care
  • A tool to share patients’ goals of care between paramedics and the rest of the multi-disciplinary team and enable care consistent with those care wishes.

The paramedics providing palliative care model supports:

  • Paramedic comfort and confidence with providing palliative approaches to care
  • Patient and caregiver abilities to manage symptoms at home
  • Decreased use of emergency departments
  • Access to palliative care supports regardless of location and time of day
  • Positive patient and family experience of care, including reduced burden of care
  • System capacity to provide care consistent with patient wishes

A small community in New Zealand developed a model to support the delivery of palliative care services across a broad geographic area. A centralized hospice serves as a hub of palliative care expertise, providing inpatient and home care services. It also consults and provides expert guidance for primary care providers who serve as the palliative care spokes within the community and at regional hospitals.

The model aims to have most palliative and end-of-life care delivered by primary care providers, with specialist palliative care services dedicated to complex cases and providing guidance where necessary.

New Zealand’s model supports:

  • Regional collaboration
  • Standardization of care and quality
  • Equitable access across the district
  • Economical use of resources
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