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Conference Abstracts

Integration of community and primary care based palliative specialty services to support the homeless and vulnerably housed


Barbara Blocki

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According to the 2019 HQO Palliative Care at End of Life Report, people prefer to die at home, however 65% of Ontarians are dying in hospital. Our homeless and vulnerably housed are particularly at risk for hospitalization at end of life due to fragile support systems and limited access to health care. As such, there is a need to bring palliative care to our vulnerably housed patients in their preferred and most comfortable settings. Patients’ care should reflect their values and wishes so they can live with the highest quality of life possible and ultimately, die comfortably where they choose.

Aims Objectives Theory or Methods

The goal of this initiative is to ensure equitable access to comprehensive palliative care for vulnerably housed individuals and to help them receive care in a manner and space that optimizes their quality of life, comfort, dignity and security in a manner that is supportive of their life circumstances.  We set out to achieve these goals through integration of a community-based Palliative Nurse Practitioner and Outreach worker in primary care. Benefits of this model include, strengthened team safety and communication, multidisciplinary team based coordinated approach to care, reduced duplication, expanded reach, and whole person patient centered care.

Highlights or Results or Key Findings

Of the patients served in 2019 by the integrated Palliative team, only 2.6% required intervention in the hospital. Less than 1% of patients serviced by this initiative were readmitted to hospital within 30 days of service. The primary contributing factor to hospital readmissions was patient acuity, housing and inability to support the patient’s medical requirements in their current setting. Qualitative data provided by patients, primary care and other external stakeholders validate the benefits of this initiative in improving access to timely person-centered care and services through building supportive and trusting relationships between the patient and care team. The team promoted meaningful attachment to primary care resulting in 33.5 % of homeless and vulnerably housed patients having a primary care clinician. Reports from the team confirmed improved communication, increased safety and expanded reach.


The integration of the palliative NP and outreach worker into existing community teams supporting the homeless and vulnerably housed has resulted in reduced hospital visits, increased number of patients achieving preferred place of care, increased primary care attachment, expanded patient reach, increased safety, improved team communication and improved patient experience.

Implications for applicability/transferability sustainability and limitations

Evaluation outcomes resulted in approval for base funding for the NP and recognition of the outreach worker role as a mandatory enabler of success and safety. This fiscal, we are working towards replicating this model in other regions including integration with the Guelph and Area OHT.

How to Cite: Blocki B. Integration of community and primary care based palliative specialty services to support the homeless and vulnerably housed. International Journal of Integrated Care. 2022;22(S2):69. DOI:
Published on 16 May 2022.


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