Bringing Comfort Home Through Two Innovative Palliative Care Programs

When facing a life-limiting illness, most Canadians say they’d like to spend their final days at home. Unfortunately, only about 15 per cent of Canadians have the palliative care resources to do this.

Programs led by faculty at the Department of Family and Community Medicine (DFCM) at the University of Toronto aim to close this gap.

Neuropalliative Program — Credit Valley Family Health Team

With a wide range of possible neurological disorders — from ALS to multiple sclerosis to dementia to stroke — and with numerous specialists often required for care, the journey to and following a diagnosis can be quite complicated. Navigating support and care in the community is often challenging for these patients and their families.

What psychological and social services are available to the patient and their family in their community? When should palliative care be the focus? Is palliative home care an option? Whose responsibility is it to arrange all of this? Who will see a patient when they can no longer visit a clinic?

With the Credit Valley Family Health Team’s pilot Neuropalliative Program, a family physician can answer these questions while providing care and helping patients and their families navigate this difficult time, including by supporting care at home.

“As a family physician, you really have this opportunity to be an anchor in your community and support community integration at all stages of disease for patients with advanced neurologic conditions,” says Dr. Nina Yashpal, family physician with the Neuropalliative Program and assistant professor with the DFCM. “You can be a constant throughout the journey and really provide comprehensive and compassionate care to a population of patients and their caregivers who often feel invisible and isolated at home.”

When patients are diagnosed with an advanced neurological illness, they are often referred to the Neuropalliative Program by neurologists, geriatricians, internists or palliative care physicians at the hospital. From there, one of the four family physicians, including DFCM faculty members Drs. Ali Damji, James Pencharz and Melissa Graham, will join their care. This involves collaborating with the patient’s family physician or serving as their family physician if they don’t have one, all while offering a palliative approach. The program also provides home visits, especially towards the end of the patient's journey when their abilities are deteriorating and they are unable to leave their home.

Although the pilot program has only been running for two years, it has been operating unofficially for longer, providing many home visits to patients, allowing them to remain where they are most comfortable while receiving the care they need. It has also been ensuring caregivers are supported, preventing burnout and helping to manage the emotional challenges of caring for a loved one with advanced neurologic disease.

“It is so rewarding being able to help patients stay home and collaborate and coordinate with others to improve care,” says Dr. Yashpal. She hopes that other communities and future family physicians will see the value of this work and will help to expand it moving forward.

Dr. Carleigh Clarke, a DFCM family medicine resident at Credit Valley who has been working with the Neuropalliative Program, shares this sentiment.

“This experience deepened my appreciation for the importance of patient-centred, home-based care and the impact it can have on improving quality of life,” says the resident. She adds that working with the program has helped her develop skills in having difficult, compassionate conversations and has highlighted the value that family physicians provide.

“I am excited to build on what I have learned and continue making a meaningful impact on patients and families.”

Oncology Symptom Management Clinic (OSMC) — Hudson Regional Cancer Program

When a patient living in Simcoe County or the District of Muskoka is diagnosed with cancer, they are often sent to the Hudson Regional Cancer Program (HRCP) at the Royal Victoria Regional Health Centre (RVH) in Barrie. While the HRCP offers great care, toward the end of a palliative cancer journey, when immunity is low and comfort is the top priority, it can be hard to access depending on a patient’s location.

“At the OSMC, we'll bring a palliative approach to cancer care to you,” says Dr. Jacky Lai, family and community physician, palliative care physician and DFCM assistant professor. “We'll bring our team. We'll bring our medications, hospital bed and supports. We'll manage your pain and your symptoms at home."

Before the launch of the OSMC in 2019, Dr. Lai says a patient’s cancer journey was often disjointed. When treatment stopped working, the transition to palliative care would be unclear.

If a patient's family physician did not feel comfortable providing a palliative approach to care — or if the patient lacked a family physician altogether — the patient would end up in the hospital emergency room seeking pain relief. It was only at this point that they would be connected with palliative care services.

With the OSMC, which runs through the HRCP, oncologists know exactly to whom to turn to navigate the next steps.

Following a referral to the program, patients can expect to connect with the team in a timely manner. From there, palliative and home care are arranged.

And while Dr. Lai and the 12 other family and palliative care physicians on the team — many of whom are DFCM faculty — are very accessible to the OSMC patients, Dr. Lai takes pride in knowing that only about 30 per cent of patients are seen in the clinic.

“The mic drop part is that most patients who are referred to our program aren’t actually seen by us,” he says. “About 60 to 70 per cent of the individuals actually get connected back to their local communities, back to their family physician or back to their local palliative care team.”

Dr. Lai says this is so meaningful to him because when the program was being developed, the patient and family advisory council was clear that they wanted to receive their palliative care as close to home as possible.

This success is part of the reason why the OSMC received the Quality Award from the Cancer Quality Council of Ontario in 2021 and why referrals grew from 30 to about 1,000 annually in just a few short years.

Looking ahead, Dr. Lai and the OSMC team hope to expand the team’s capacity so they can support more patients with cancer. One day, they’d like to expand to services to palliative patients experiencing other illnesses.

Originally published in the 2024-2025 Family Medicine Report. Read the full report