PRIORITIES / Operational Excellence in Home-Based Palliative Care


Sharing of knowledge and best practices among home and community-care providers across the country is an effective strategy for strengthening and accelerating the development of operational excellence in palliative care. Through the identification, documentation and dissemination of leading practices, stakeholders can access expertise to address common challenges.

High Impact Practices

High Impact Practices, as defined by the CHCA are evidence-informed, innovative practices within the community and home-based care sector that enhance the quality and effectiveness of service and result in improved quality of life for clients and their families.

Implementing a Palliative Approach to Care by Having Conversations Early (IPACE)

From Vancouver Coastal Health in British Columbia – A process to empower front-line staff to incorporate early conversations with patients about their goals for care.
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Rural Palliative Care In-Home Funding Program

From Calgary Zone, Alberta Health Services – A flexible approach to enhancing care for rural patients nearing end of life.
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The INSPIRED COPD Outreach Program

From Nova Scotia – A program to provide enhanced social supports and advance care planning throughout an individual’s illness trajectory
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Virtual Palliative Care Intervention

From William Osler Centre in the Greater Toronto Area – A model that combines an app for early identification of symptoms with videoconferencing to help support palliative care patients in the community

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Whole Community Palliative Rounds

From Interior Health in British Columbia – A strategy to support multi-disciplinary communication and shared decision-making

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Medication and Supplies Management Evidence Synthesis

An important part of home-based palliative care is the safe and effective management and disposal of equipment, supplies and medication. Patients and caregivers experience the burden of not only purchasing equipment, but also ensuring its removal and safe disposal. To gain a better understanding of potential opportunities and leading practices in this priority area, the CHCA conducted a review of research evidence and grey literature specifically on access, management and disposal of medications and supplies in home-based palliative care.

Download the top 10 considerations for managing medication and supplies
Download the Medication and Supplies Management – Evidence Synthesis

Call for Leading Practices

Building on the knowledge gained through the extensive consultations, the CHCA conducted a national call for operational innovations in home-based palliative care. The call focused on finding leading practices that address the gaps identified in the experience maps.

Advance Care Planning

Access to Advice and Advance Care Planning – An Edmonton Perspective – Advance Care Planning/Goals of Care, the collaboration with Community Emergency Medical Services with an Assess Treat & Refer program, and new ways of accessing technology and caregiver feedback will be presented. Download Presentation

Utilizing Interpreters to Support Culturally Sensitive Goals of Care/ Advance Care Planning Discussions – An interactive online course that helps interpreters critically reflect on their interpretation of the questions in the Serious Illness Conversation Guide. Download Presentation    |    Watch video

Responding to Policy Issues: How a Provincial Advance Care Planning/Goals of Care Designation Community of Practice Promotes Excellence – The development of a provincial ACP/GCD Community of Practice, a centralized meeting place for ACP champions to share, learn, and interpret the provincial policy and procedure. Download Presentation     |     Watch video

Rural in-Home Palliative Care Program- Components and principles of an innovative rural funding model to augment in-home palliative care services. Presentation PDF       Watch video

Integrating a Palliative Approach to Care by Having Conversations Early (IPACE)- Facilitating early conversations using Ariadne Lab’s Serious Illness Conversation Guide (SICG) or other conversation tools to respect individual’s these wishes regardless of the setting of care and to foster this change in practice as part of the clinician’s daily work. Presentation PDF    Watch video

Advance Care Planning Framework – An advance care planning framework that provides guideposts and reinforces the continuous and progressive process of conversations with family, friends and health care provider(s). Presentation PDF     Watch video

Assessment and Delivery

Telepalliative Care – Co-designed with the Ontario Telemedicine Network this virtual approach to palliative care supports timely symptom assessment for adults across the region who prefer to receive care in their home. Presentation PDF          Watch video

Integrated Palliative Care Approach in Home Care – The integrated clinical care delivery approach is a shared model integrating the Extra-Mural Program (EMP) and the Residential Hospice (RH) – privately owned and operated by the community hospice association, primary care and other community resources. Presentation PDF    Watch video

Virtual Palliative Care: Right Patient, Right Time, Right Place, Right Care – The RELIEF (Remote self-reporting of symptoms by patients) application allows for patients with palliative care needs to self-report their symptoms daily, in their homes, using electronic standardized assessment tools. Their status is monitored in real time and thus allows for more timely and appropriate responses by health care providers.  Presentation PDF       Presentation and video

Continuum of Care for Clients with Advanced Heart Failure (HF) – A collaborative clinical partnership for home nursing involvement and follow-up for individuals with advanced heart failure to recognize and rapidly treat exacerbations in the home.   Presentation PDF        Watch video

Equipment and Medication

End-of-Life Symptom Management Kit for use at Home in Rural Northwestern Ontario – Designed using best practice and evidence-based research, this is a standardized palliative symptom management kit which includes necessary medications and medical supplies required to treat the most common end-of-life symptoms.       Presentation PDF      Presentation and video

Cost Benefit of Elastomeric Infusors in a Residential Palliative Care Setting – This initiative examined the cost associated with using elastomeric infusors (not CADD pumps) and compared it to the cost of regularly administered medications by conventional methods. Aspects considered include nursing time, supply usage, and medication wattages.  Presentation PDF

Using Electronic Clinical Management Systems to Drive Best Practices in Palliative Care – Electronic order sets that guide correct formulation and dispensing guidelines and supports physicians with decision making when transitioning from oral to infusion-based medications.Electronic order sets that guide correct formulation and dispensing guidelines and supports physicians with decision making when transitioning from oral to infusion-based medications.  Presentation PDF     Watch video


Whole Community Palliative Rounding: An Innovative, Collaborative Approach for Rural BC – Population-based “Whole-Community Palliative Rounds” is used in rural communities to facilitate a process for inter-professional sharing of collective clinical expertise and knowledge to address the immediate palliative care needs of persons and families. Presentation PDF    Watch video

Reducing the Silo Mentality – This innovation builds collaboration between established health care programs who traditionally work in silos, to provide seamless palliative care to a population of frail seniors that have not previously been able to access palliative care services. Presentation PDF      Watch video

Integrated Palliative Care Approach in Home Care – An interdisciplinary, interdepartmental team model comprised of the client and their family/caregiver(s), palliative trained nurses and personal support workers (PSWs) that is strategically designed to encourage and promote communication. Presentation PDF    Presentation and video

Spectrum Health Care’s Operational Excellence in MAiD – Build on three core perspectives – patient/caregiver, provider and system; this MAID (medical assistance in dying) program uses clear protocols, procures and rigorous training to support community nurses and team-based care. Presentation PDF

The Integration of Palliative Home Care Services and Acute Care Teams in the Provision of Medical Assistance in Dying in the Community – In 2016, the Champlain LHIN Palliative Home Care Program joined forces with The Ottawa Hospital (TOH) in order to provide MAiD to palliative patients in the community. Palliative home care services now support acute care physicians in offering MAiD in the community, resulting in care that is more patient-centered and with improved communication.  Presentation PDF

The INSPIRED COPD Outreach Program™: Role of the Advance Care Planning Facilitator – As part of the INSPIRED COPD Outreach Program a trained advance care planning facilitator provides in home psychosocial/spiritual support, assisting patients/families in completing personal directives if desired. Presentation PDF     Presentation and video

Redefining the Circle of Care – A quality improvement initiative that sought to refine and expand the circle of care so as to better meet the palliative needs of people. Presentation PDF    Watch video

Provincial Palliative Care Consultation Phone Line – The toll-free Provincial Palliative Care Consultation Phone Line is a partnership between Doctors of BC and the Vancouver Community Home Hospice Palliative Care physicians. Presentation PDF    Watch video

The New Normal: The Palliative Clinical Resource Nurse Role in Community Home Health – An approach to embedding palliative clinical resource nurses (PCRN) into  home health sites and providing a vital link between acute care, residential care, hospice and community care. Presentation PDF      Watch video

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