Specifically, the plan highlights actions to improve the way health authorities, physicians, health care providers and community organizations are serving the needs of end-of-life patients and their families.
The plan seeks to reduce the need for hospital visits and to increase support for individuals with life-limiting illnesses to stay in their homes. The action plan applies a “population needs-based approach” to the issue of palliative care in effort to acknowledge that the needs of end-of-life patients vary and shift over time. To meet this often-complex set of needs, the plan suggests that an integrated team approach- made up of the patient, the patient’s family, the family physician, specialists, nurse practitioners, community health teams- is most effective. Through this integrated care approach, the individual’s beliefs, values and wishes are meant to guide discussions and planning for care.