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
  1. Lavis JN, Hammill AC. Care by sector. In Lavis JN (editor), Ontario’s health system: Key insights for engaged citizens, professionals and policymakers. Hamilton: McMaster Health Forum; 2016, p. 209-69.
  2. Tremblay D, Latreille J, Bilodeau K, et al. Improving the transition from oncology to primary care teams: A case for shared leadership. J Oncol Pract. 2016;12(11):1012-1019.
  3. Tremblay D, Prady C, Bilodeau K, et al. Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies. BMC Health Serv Res. 2017;17(1).
  4. Meiklejohn JA, Mimery A, Martin JH, et al. The role of the GP in follow-up cancer care: a systematic literature review. J Cancer Surviv. 2016;10(6):990-1011.
  5. Kang J, Park EJ, Lee J. Cancer survivorship in primary care. Korean J Fam Med. 2019;40(6):353-361.
  6. Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
  7. Cancer Quality Council of Ontario. Programmatic Review on the Diagnostic Phase: Environmental Scan.; 2016.
  8. Gorin SS, Haggstrom D, Han PKJ, Fairfield KM, Krebs P, Clauser SB. Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Ann Behav Med. 2017;51(4):532-546.
  9. Mittmann N, Beglaryan H, Liu N, et al. Examination of health system resources and costs associated with transitioning cancer survivors to primary care: A propensity-score–matched cohort study. J Oncol Pract. 2018;14(11):e653-e664.
  10. Zhao Y, Brettle A, Qiu L. The effectiveness of shared care in cancer survivors-A systematic review. Int J Integr Care. 2018;18(4):2.
  11. Angus Reid Institute. (2023). Health Care Access Priorities. Angus Reid Institute. Accessed December 4 2023. Available: https://angusreid.org/cma-health-care-access-priorities-2023/
  12. Kiran, T. (2023). Our Care National Survey. Our Care. Accessed October 13 2023. Available: https://data.ourcare.ca/all-questions.
  13. Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
  14. Canadian Residency Matching Service. 2023 CaRMS Matching Results. Accessed December 12 2023. Available: https://www.cfpc.ca/en/education-professional-development/2023-carms-match-results.
  15. Canadian Institute for Health Information. Commonwealth Fund survey, 2020. Accessed October 13, 2023. Available: https://www.cihi.ca/en/commonwealth-fund-survey-2020.
  16. Jensen, H. Implementation of cancer patient pathways and the association with more timely diagnosis and earlier detection of cancer among incident cancer patients in primary care. PhD dissertation. Aarhus University; 2015
  17. Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ. 2015;351:h5102
  18. Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM. Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer. 2011;105(6):753-759.
  19. Canadian Partnership Against Cancer. Leading Practices to Create a Seamless Patient Experience for the Pre-Diagnosis Phase of Care: An Environmental Scan. 2018. Accessed November 22, 2021. https://canimpact.utoronto.ca/wp-content/uploads/2018/04/Leading-Practices-to-Create-a-Seamless-Patient-Experience-for-the-Pre-Diagnosis-Phase-of-Care-CPAC-2018.pdf
  20. Walsh J, Young JM, Harrison JD, et al. What is important in cancer care coordination? A qualitative investigation: What is important in care coordination? Eur J Cancer Care (Engl). 2011;20(2):220-227.
  21. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. 2015;313(14):1417-1418.
  22. Lewis RA, Neal RD, Hendry M, et al. Patients’ and healthcare professionals’ views of cancer follow-up: systematic review. Br J Gen Pract. 2009;59(564):e248-59.
  23. Cancer Council Victoria. Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer Draft for National Public Consultation.; 2017. Accessed November 22, 2021. https://apo.org.au/sites/default/files/resource-files/2017-09/apo-nid108366.pdf
  24. Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. Aust J Gen Pract. 2020;49(5):288-292.
Previous: First Nations, Inuit and Métis
Next: Optimizing scope of practice