Integrating end of life care to help people stay in the community: The essentials for success

This knowledge synthesis grant focuses on understanding and supporting the complex needs of patients and their family caregivers who are dealing with multiple chronic conditions and/or life limiting illnesses. The project will synthesize the evidence for what community-based resources are critical in the last year of life for patients and their family caregivers, how a case management approach can improve the integration of these resources into innovative community-based palliative care models, and the challenges different practice settings face when trying to use a case management approach. Innovative community-based palliative care models implement a case management approach early in the trajectory toward end of life to bridge the transition into palliative care, and improve access to community resources that have been shown to improve patient and family caregiver care, experiences and outcomes. During the grant we will engage individuals who deliver and receive community-based palliative care to get their perspectives on what literature we should synthesize to ensure our final product addresses their needs. Our final product will provide a report on our findings along with recommendations for enhancing the implementation of innovative community-based palliative care models that address the complex needs of patients and family caregivers in the last year of life into bereavement.