Details
Documented assessment of palliative care needs among patients identified to benefit from palliative care (long-term care sector)
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Most patients in our health care system should be receiving a palliative care approach much earlier than they often do. Ultimately, receiving timely palliative care provides benefits for patients, caregivers and the health system, often supporting patients to die in their preferred place of death with the supports they need. Health care providers in all sectors have a role to play in identifying patients who could benefit from a palliative care approach.
Click here for a visual guide outlining how to measure this indicator.
Tips
- You can select one or more of the change ideas or tools below and use this PDSA worksheet to help test your change ideas. You can learn to select the most appropriate process indicators by reading this Measurement Guide.
- To prioritize a change idea to include in your QIP, consider choosing one that addresses a known gap within your care team (i.e., ensuring care teams have confidence to have difficult conversations); standardizes or enhances an existing process (i.e., choosing an early identification tool and developing a process to identify); and/or provides an opportunity to build greater patient and caregiver engagement (i.e., create a palliative care plan to support patients and caregivers).
- Email palliative@hqontario.ca to join the mailing list for monthly webinars and other supports.
Key resources
- Palliative Care Care for Adults With a Serious Illness Quality Standard by Ontario Health
- Tools to Support Earlier Identification for Palliative Care by the Ontario Palliative Care Network
- The Palliative Care Toolkit by the Ontario Palliative Care Network
- The Ontario Palliative Care Competency Framework by the Ontario Palliative Care Network
- Patient Centred Decision Making Implementation Tools
Change Ideas
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Select and use tools that support early identification
- Review the Tools to support Earlier Identification for Palliative Care toolkit, then:
Engage staff in choosing and testing the tool to ensure uptake
Embed the chosen tools into your electronic medical record system
Use flags in EMR when changes in medical or functional status occurs to prompt clinicians to screen or re-screen for palliative care needs
Ensure patients identified early have a holistic assessment completed
- Educate interprofessional staff on the Domains of Issues Associated with Illness and Bereavement
Domains of Issues Associated with Illness and Bereavement - Map out current assessment process to assist in determining gaps
Process Mapping Instructions and Worksheet by Health Quality Ontario
- Develop a future state process to leverage interprofessional team members’ expertise to complete the holistic assessment and plan ongoing care
- Provide education and skills training to staff on communication and having difficult conversations
Hospice Palliative Care Ontario’s Implementation Resources - Provide guides or prompts for clinicians to help them in having difficult conversations
Person-Centred Decision Making (PCDM): Advance Care Planning, Goals of Care Discussion and Health Care Consent Tool Kit by Speak Up Ontario - Review information guides, pamphlets and brochures with care team members to ensure they feel confident discussing content with patients and families
- Create a care plan in a format that can be shared with patients
Coordinated Care Plan user guide and template by Health Quality Ontario
- Explore opportunities for digital tools and technology for palliative care planning and referrals
Enhancing Long-Term Care Through Electronic Clinical Support Tools - Explore virtual platforms for connecting with specialists or with patients, especially in remote areas
The Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs - Reach out to your Regional Palliative Care Network to get information on supports and partners in your area
Contact info@ontariopalliativecarenetwork.ca to get more information - Share resources (staff, technology, or training opportunities) amongst partners in your region (i.e., sharing and co-funding an NP amongst partners within a region, holding regional educational events)
- Ensure personal support workers have a way to alert registered staff or document when they notice a change in resident status, especially for those patients who have already been identified with palliative care needs.
- Provide education and training to staff in required palliative care competencies
View courses provided by Pallium Canada and leverage resources from Hospice Palliative Care Ontario and the Ontario Palliative Care Network - Develop a process to determine if staff skill and confidence is improving, incorporating audit and feedback
How to Conduct an Audit for Your Training Programs by HR Daily Advisor
- Provide education and skills training to staff on communication and having difficult conversations
Support health care providers in communicating with patients and their families about palliative care
Foster collaboration and communication internally and across care settings
Ensure providers have the skills and confidence to provide palliative care
- Review the Tools to support Earlier Identification for Palliative Care toolkit, then:
Last Updated: August 26, 2026
