Palliative Care Initiative

Better care at the end of life

Despite the best in medical science and technology, many patients with advanced, life-limiting illnesses suffer needlessly in the final stages of their lives and die in ways that leave their families with legacies of pain. The growing number of people living with chronic, incurable illnesses highlights the urgency of developing pathways of care that ensure provision of high quality care while avoiding unnecessary and unwanted care in the final phases of life.

Society’s challenge is to redesign health systems and routine operations to make it easier for providers to do the right thing, consistent with clinical realities and patients’ values and preferences.

How CCNC can help

A number of innovative demonstration projects in palliative and end-of-life care have shed light on practical and effective ways for improving quality and access to care for incurably ill patients and their families. What has been surprising is the degree to which the projects have shown that introducing elements of palliative care “upstream” in the course of illness, concurrent with life-prolonging treatment, is associated with controlling costs. In striving to enhance quality, these projects improved health system efficiency and health resource use.

Such results are achieved by coordinating care and facilitating communication between patients, families and providers; by enhancing patients’ sense of personal control; and by assisting patients with advanced care planning and decision-making that reflected their personal values and preferences.

Of particular relevance to CCNC networks were demonstration projects which achieved enhanced quality and access to care at the end of life through the integration of palliative care with traditional care management services. Through improved communication and coordination of services, the projects prevented or responded quickly to medical crises or problems when they arose, thereby diminishing emergency room visits, hospital stays and days-of-care in an intensive care unit.

Aims of the Palliative Care Initiative

  1. Improve information dissemination and access to hospice and palliative care services
  2. Enhance patient autonomy through increased use of advance care planning communication in primary care practices
  3. Develop and disseminate clinical tools for pain and symptom management, psychological, spiritual and practical needs appropriate for primary care practices serving seriously ill patients.


Specific Activities have included:

  • Development and deployment of a community palliative care resource assessment and provider survey within each regional network
  • Assessment results were collected and used to create a region-specific information resource for hospice and palliative care referrals
  • Primary care providers surveyed and results used to define practice improvement and training needs
  • Development and delivery of a curriculum and toolkit for Care Managers to enhance clinical skills in advance care planning communication, screening and assessment of major sources of patient distress in serious illness, and screening for hospice
  • Enhancing systems to incorporate primary care documentation tools for key components of advance care planning, such as living wills, Health Care Powers of Attorney, portable DNR orders, and portable MOST forms
  • Fostering the development of local Quality Improvement initiatives for End of Life/Palliative Care in CCNC networks