Grant: Health System Impact Fellowships - PostDoc Central Canada 2 year

Caring for cancer patients as they approach their final year of life needs to be improved. Many patients are not receiving timely or appropriate symptom relief. Despite preferring to die at home or in hospice, patients die in the hospital or in the emergency department. By breaking down silos, and integrating care across the community and with the patient, we can improve care during the final stages of life. We propose to do this by increasing communication and integration with our family physicians, specialists, hospitals and ambulance services (by electronic records, or telecommunication) such that patients can avoid a hospital admission. Electronic records would include patients' wishes outlined in their advanced care plan. We also propose to improve processes for patients to be directly admitted to hospice, palliative care units or necessary hospital admissions. Our goal is to have patient management aligned with their preferences and to decrease the number of hospital admissions, emergency department visits and associated wait-times.