Improving Equity in Access to Palliative Care

Alberta Health Services is an integrated health authority that delivers services provincially. Alberta Health Services – North Zone partnered with Cold Lake First Nations Health Centre on a program called Gathering Voices, Honouring Care in Bonnyville, Alberta. Together they: 

• Hosted a series of community engagement gatherings that built capacity to provide culturally safer palliative care to 46 care providers and Cold Lake First Nations community members.

• Developed stronger collaboration and coordination across care partners.

• Ensured more choice for individuals living on Cold Lake First Nation to receive culturally safer palliative care within their community.

The gatherings improved collaboration and care coordination between the North Zone palliative care team, the Indigenous liaisons from Cold Lake Health Care Centre and Cold Lake First Nations.

The Champlain Hospice Palliative Care program (CHPCP) supports organizations that provide or wish to provide palliative care across the Champlain Region. CHPCP works with organizations that want to serve clients better and improve access to a palliative approach to care.

CHPCP partnered with Tungasuvvingat Inuit, Ottawa Inner City Health and The Diane Morrison Hospice at The Ottawa Mission, and Carleton University. Together they:

• Implemented a cultural/spiritual support person for Inuit at the Diane Morrison Hospice and The Oaks aging-at-home program.

• Provided the  Building the Circle of Care: Walking Alongside train the trainers education for community caregivers.

• Held gatherings to listen to Inuit community members and the health and social care providers working directly with Inuit to understand the journey for Inuit community members experiencing homeless or facing housing stability in receiving palliative care. 

They developed links between different community members and health and social care providers. These relationships will assist the partners in continuing efforts to improve a palliative approach to care for Inuit in Ottawa.

Dorothy Ley Hospice (DLH) and GPS Health Navigators partnered with Hope House Community Hospice and COMPASS Community Health Centre to improve access to palliative care for people living with refugee status.  

DLH is a volunteer-based community service organization offering compassionate care to people living with serious illness or loss. We believe every person deserves to be celebrated, valued, and supported. We embrace diversity in all its expressions, honour each person’s story, and are inclusive in all that we do. In keeping with our commitment to continually identify innovative approaches and solutions to hospice palliative care challenges, DLH proudly collaborated with GPS Health Navigators to support the launch and growth of its innovative program addressing the palliative care needs of refugees across the Greater Toronto and Hamilton Area (GTHA). Together these four agencies:

• Established a system navigation service to ensure vulnerably housed refugees with Interim Federal Health Insurance and palliative care needs are connected with appropriate multi-disciplinary services by four nurse navigators.

• Engaged stakeholders through education sessions and coaching on the nuances of palliative care provision to refugees.

• Brought awareness of insurance barriers for this population among community partners and need for better access to palliative care for refugees at the federal level following new and significant cost barriers.

This initiative increased access to palliative care services for vulnerably housed refugees across the greater Toronto and Hamilton areas.

The Fort Erie Native Friendship Centre (FENFC) supports Indigenous people in Fort Erie and offers programming for all stages of life including family services, youth-based programs, lifelong care, employment and training. FENFC partnered with Hospice Niagara on this initiative. Hospice Niagara works alongside communities—not to lead, but to listen, learn and co-design palliative care, grief support and caregiver services that reflect each community's unique strengths, cultures and priorities. Together they:

• Developed a sustainable volunteer peer-support program informed by an Indigenous approach to palliative care.

• Engaged Indigenous community members to ensure the program reflected community needs.

• Improved access to culturally safer palliative care for structurally vulnerable people living in the Fort Erie community.

The partnership strengthened relationships between the Fort Erie Native Friendship Centre and Hospice Niagara, creating new opportunities to share knowledge and build capacity. As one team member reflected, “This collaborative has brought two organizations together allowing for shared knowledge, experience and partnerships that didn’t exist before.” Both organizations are committed to continuing to recruit and train volunteer peer supporters to improve access to culturally safer palliative care.

The  George Spady Society provides a continuum of support services at George’s House to people with complex life circumstances and empowers them to improve their lives through client-centred, evidence-informed best practices.

Through the collaborative they:

• Developed and strengthened their housing-based palliative care model, designed to support people regardless of substance use. Integrated a client engagement role enabling wrap-around supports for outreach, coordination and transition of clients into the program.

• Strengthened partnerships with health system and community partners improving referral pathways and coordination of care.

• Consulted with and documented the insights of residents, staff, partners and other healthcare providers on what makes a housing-based palliative care approach work for people experiencing homelessness.

The initiative strengthened a housing-based model serving structurally vulnerable individuals that provides compassionate, culturally-informed palliative care for people who might otherwise die without appropriate support.

Learn more:

• A Morning at George's House (video)

• From framework to impact: Equity oriented care in practice (video)

• George's House — George Spady Society

The Grey-Bruce Ontario Health Team is a collective of community health and social service organizations and care providers who strive to collaboratively serve their unique communities, provide integrated healthcare services and improve healthcare delivery. Brightshores Health System (BHS) is a partner of the Grey Bruce OHT, operating six hospitals in the Grey Bruce region and offers a range of rural acute care and specialty services.

Through the IEAPC Initiative, the GBOHT and BHS partnered with Saugeen First Nation, Chippewas of Nawash Unceded First Nation, Grey and Bruce Counties, Southwest Ontario Aboriginal Health Access Centre, Home and Community Care Support Services, Grey Bruce Hospice, Safe n’ Sound, the Grey Bruce Palliative Medicine Group and many other social and health service partners to assess community needs and co-design a dedicated social navigator role aimed at improving equity in access to palliative care for individuals who identify as Indigenous, and/or who are homeless or vulnerably housed. The IEAPC Navigator position was created to directly extend a palliative approach to care for the priority populations in April 2025.

The IEAPC Navigator Position:

• Advocates for clients

• Connects people with health and housing supports

• Provides trauma-informed and culturally safe(r) care

• Helps identify people who would benefit from a palliative approach to care

• Provides coordination and supports transportation to ensure clients get the care they need

• Supports development and improvement of connections to community health and social service supports

Implementation of the IEAPC Navigator role improved access to and coordination of palliative approaches to care for those experiencing homelessness or housing vulnerability in the community. This position has been extended through OHT and community support until March 31, 2027.

Huron Shores Family Health Team is a not-for-profit healthcare organization providing high-quality, interdisciplinary primary care and improves the health, well-being and quality of life of residents.

They partnered with North Shore Health Network to develop and implement a referral pathway for their palliative care program that mitigates structural barriers and improves access for individuals experiencing homelessness or vulnerable housing. To accomplish this, they:

• Conducted a needs assessment to understand gaps and challenges in accessing care for people experiencing homelessness or vulnerable housing.

• Created a referral pathway, a system navigation plan and established a palliative care committee to address the palliative care needs of this population.

• Strengthened communication and collaboration with community partners to increase awareness of individuals experiencing homelessness and vulnerability.

Building trusted relationships laid the foundation for culturally safer care. As the team reflected, “Meaningful relationship-building requires time, consistency and trust. Establishing culturally safe and respectful partnerships cannot be rushed and must be grounded in ongoing dialogue and mutual understanding.”

Kingston Community Health Centres (KCHC) provides integrated services that empower people and builds community. KCHC is a close partner with the Frontenac, Lennox and Addington Ontario Health Team’s Vulnerable Population-Focused Palliative Care Strategies working group, which comprises healthcare, social service, and community support organizations serving vulnerable populations. It brought together people who don’t always get to sit in the same room: palliative care specialists, housing and shelter staff, Indigenous Elders, community organizations, paramedics and hospice workers. Collectively, they laid out, step-by-step, what really happens when a structurally vulnerable person gets seriously ill. Together they:

• Conducted journey mapping with community partners to identify barriers, including limited access to primary care, and opportunities to improve care.

• Developed a direct referral process from frontline workers to Queen’s Palliative Medicine’s community outreach team.

• Held reciprocal education sessions to provide palliative care education to community workers, harm reduction education sessions to palliative physicians and equitable palliative care education to medical providers.

• Initiated ongoing patient rounds and an intersectoral working group. In 2026 it grew into a community of practice, opening supports and education to more local organizations serving vulnerably housed people.

The initiative highlighted the importance of relationships and community. It became a space for honest discussions across sectors, to find solutions together and learn from each other’s experiences and expertise.

Founded in 1969, Maison du Père is renowned for its innovative spirit and expertise supporting people experiencing homelessness. Over the years, the organization has developed a continuum of promising practices to prevent and reduce homelessness, including homelessness prevention services, an emergency shelter and referral service, assistance finding and keeping housing, social reintegration, a residence for seniors experiencing homelessness and Accès Santé, a specialized and palliative health care wing for people without an address. Maison du Père also partnered with the Palliative Home-Care Society of Greater Montreal and the Fondation Virage, as well as several other community, institutional and hospital partners.

Through this collaborative, Maison du Père successfully:

•  Improved the experience of participants, their loved ones and providers by establishing a coordinated, compassionate and harm reduction-based approach,

•  Integrated the palliative approach to care into all existing clinical services and developed new tools to support conversations about serious illness, care goals and advance care planning,

•  Strengthened collaboration and referral mechanisms between community, institutional and hospital partners,

•  Helped develop a continuum of care that supports a significant increase in access to specialized and palliative health care for people experiencing homelessness,

•  Supported the development of new initiatives, including Maison Mobile, which leverages a close collaboration between community partners and the health system to meet people experiencing homelessness where they are and provide palliative care services in those locations.

Major impacts: Palliative approaches to care are now part of the clinical and organizational culture of Maison du Père. Lessons learned from the project also informed new practices, partnerships and innovative initiatives like Maison Mobile, increasing equitable access to care, improving the quality of services and expanding the continuity of care for people experiencing homelessness.

Learn more:

• Un refuge avec des lits de soins spécialisés | La Presse (French)

• La collaboration au service des personnes en situation d’itinérance | Santé Québec Centre-Sud-de-l’Île-de-Montréal – Universitaire | Facebook (French)

Medavie Health Services West - Moose Jaw partnered with Square One Community Moose Jaw Inc., Thunder Creek Rehabilitation Association, Saskatchewan Health Authority and the Moose Jaw Age Friendly Committee. 

Through its community paramedic program, Medavie Health Services West - Moose Jaw and partners focused on strengthening partnerships, enhancing care pathways, and increasing awareness of palliative needs within community-based and non-traditional care settings through the development of wellness clinics.  

The development of wellness clinics improved access to care for structurally vulnerable members of the Moose Jaw community.  

Over the course of the collaborative, they served over 1,800 people. By offering palliative-informed care in safe, familiar community settings, Medavie’s community paramedic team reduced structural, cultural, and psychological barriers for people who often avoid the health system due to trauma/stigma. Most of their clients reported they would not have sought care elsewhere without the clinic, demonstrating improved safety and equitable access for unhoused individuals.

Newfoundland and Labrador Health Services (NLHS) delivers high-quality healthcare to all residents of the province through a range of programs. 

The Eastern Urban Zone of NLHS, as part of the Downtown Health Collaborative, partnered with End Homelessness St. John’s to improve health services and access to palliative and end of life care in the St. John’s Metro area. 

They focused on relationship-building, increasing awareness, improving early identification and strengthening collaboration between primary care, specialized palliative care providers and housing providers. They created dedicated palliative care beds in transitional housing and enhanced access to palliative care and clinician supports within supported housing settings.  

The initiative highlighted that relationship building and collaboration strengthens systems and improves access: It encouraged dialogue within teams and across partner organizations about the barriers that individuals experiencing homelessness, housing instability and substance use face when accessing traditional palliative care services. 

Newfoundland and Labrador Health Services (NLHS) provides programs and services to the people of Newfoundland and Labrador through facilities, clinics, and community services, overseen by the health zones.  

NLHS – Labrador-Grenfell Zone and community partners implemented a model of care through the Nain Community Clinic that enabled community members to receive palliative care within their community and homes, reducing the number of individuals who must travel outside of their remote community to receive palliative care. 

Nurses, support staff, patients, families and communities developed an understanding “that palliative care is something we can do together, that we provide competently and effectively, without community members having to ever leave the comforts of home.” Together they integrated effective pain management through the implementation of appropriate technology, offering education to support its use and the development of Indigenous-focused end-of-life approach to ensure standardized pain management with a culturally focused, holistic approach. 

As the team reflected, “Our communities feel empowered, like we are reclaiming a part of our history that was taken during colonization.” 

NiGiNan Housing Ventures is an Indigenous-led registered charity serving those hardest-to-house with complex medical, social and housing needs. They provide care and support for all areas of their lives and access to Indigenous ceremonies and culture. Niginan Housing Ventures partnered with Kokums Helper Society and other partners such as George’s House. 

Together they built trust, consistency and space for people to connect with culture, spirit and community in their own way. Through an Indigenous Palliative Care Auntie role, they: 

• Supported more people in receiving palliative care,

• Helped families feel less alone and more supported, 

• Helped staff gain confidence and cultural understanding, 

• Built stronger and more connected care teams. 

This initiative highlighted that culture is medicine. As Jackie DeCoteau-Gill, Indigenous Palliative Care Auntie, reflected, “My role provides opportunity for relationship building even after the care for the resident is completed. The Indigenous worldview is relationship based, and I can continue the relationships that are forged in a time of transition.”  

Nova Scotia Health provides health services to Nova Scotians and some specialized services to Maritimers and Atlantic Canadians. It operates hospitals, health centres and community-based programs across the province. Nova Scotia Health partnered with  Adsum, Northwood , VON and other community partners to serve the most vulnerable. To improve access, partners worked together to integrate palliative care principles into The Bridge, an integrated shelter with on-site social and health services. The team: 

• Designated two accessible rooms to support palliative residents with essential equipment, supplies and supports including access to Nurse Practitioner led clinic, 

• Provided comprehensive palliative care training to all shelter staff, 

• Co-developed specialized curriculum on specialty palliative care team about care of the unhoused population 

• Improved cross-sector coordination, resulting in greater integration across housing and health.

 The work underway at the Bridge Shelter to bring health and social systems together is life changing for residents at the Bridge. Having an onsite clinic means residents can access these services outside of hospital. There has been a 45% reduction in emergency department admissions in Halifax Regional Municipality for people experiencing homelessness and a 40% reduction in patients leaving against medical advice. This work is having a real impact on reducing stigma and ensuring that people are getting the care they deserve. In closing, the on-site leadership and wrap-around health and social model of care is foundational to the success of improving equity in access to palliative care. 

Scarborough Centre for Healthy Communities provides accessible, equitable and transformational health and social service choices for the well-being of diverse communities. They partnered with Palliative Education and Care for the Homeless (PEACH), a program of the Inner City Health Associates (ICHA), to address a rapid increase in the number of Scarborough residents who have overlapping housing insecurity, marginalization and palliative care needs. PEACH is a partnership between ICHA, Toronto Centre Home and Community Care Support Services and Kensington Health. 

Through the collaborative, they developed and implemented a sustainable regional PEACH model of care in Scarborough. This included a needs assessment, providing education to build capacity in harm reduction and trauma-informed care resulting in multi-disciplinary teams that were better equipped to provide compassionate, equitable and person-centred palliative care within community settings. 

Through this initiative, clients have been able to access care through a trauma‑informed and equity‑focused lens tailored to the unique needs of the Scarborough community. 

The Second Mile Club of Toronto at Kensington Health supports older adults and people living with disabilities in the community including at Kensington Hospice. The Kensington Hospice supports adults in the community who are living with a life-limiting illness. 

The Second Mile Club of Toronto and the Kensington Health partnered with The Neighbourhood Group and Palliative Education and Care for the Homeless (PEACH) program, through the Inner City Health Associates. 

The team developed and implemented a peer-worker role. By recruiting, training and integrating individuals with lived experience into the interdisciplinary team at Kensington Hospice they enhanced relational, emotional and practical support for patients, families and providers. 

Peer workers each brought unique life experiences which supported their ability to connect with and advocate for patients and their caregivers, family, chosen family and friends. The presence of peer workers influenced team members to approach care with more empathy, patience, and relational awareness. 

The Palliative Home-Care Society of Greater Montreal enables people in the advanced stages of cancer or other life-limiting illnesses to conclude the final chapter of their lives in comfort by using a flexible and mobile model. Through the collaborative, the Society successfully:

• Cared for over 70 people receiving palliative care while experiencing homelessness in the living situation of their choice including shelters, camps, or temporary housing.

• Conducted more than 50 training sessions for workers and healthcare professionals on an integrated palliative approach in the context of homelessness.

• Designed and implemented a sustainable outreach model that enables individuals to receive palliative care in the environment of their choice.

• Developed resources to support reciprocal knowledge exchange within the community to better understand palliative approaches to care and the unique needs of people who are experiencing homelessness or precarious housing.

Notable impacts: Stronger relationships and better care. Through new relationships and mobile outreach, more people are receiving accessible care. A relationship was built with St. Raphaels Home that will facilitate patients receiving increased access to allied care and bed-based care.

Learn more:

• Palliative Care at Home 💚 Official: Facebook | Linktree

• Des soins palliatifs mobiles pour les itinérants en fin de vie | Radio-Canada (French)

• Montreal health-care program offers palliative care to the unhoused - Montreal | Globalnews.ca (English)

The Salvation Army Crossroads Residential Services offers a Male-Identified Emergency Shelter program and the New Frontiers' Correctional Services Canada's halfway house program. Crossroads provides the Emergency After-Hours Program to support the vibrant community surrounding it. Crossroads partnered with Medavie Health Services West for the collaborative. 

Through the collaborative, Crossroads successfully embedded community paramedicine service clinics at The Salvation Army sites. These focused on improving proximity to streamlined and dignified care within its shelter sites including designated beds for those with medical needs.  

Community paramedics also strengthened prevention and health-literacy by co-facilitating sessions for staff on addiction, grief, mental health, hope and health impacts of housing improving collaboration, relationships and trust between social and health care staff as well as between staff and clients.  

By integrating community paramedics into shelter settings, this initiative advanced equity, continuity, and early access to palliative informed care, reduced avoidable emergency department use and provided earlier, relationship-based and trauma-informed symptom relief and follow-up. 

Thunder Bay Palliative Advocacy & Care Team (PACT) provides primary healthcare and social services in the Thunder Bay community and surrounding District. PACT partnered with Hospice Northwest, St. Joseph’s Care Group Northwest Regional Palliative Care Program, Thunder Bay Palliative Care Associates, the Lakehead University Centre for Education and Research on Acting and Health (CERAH), NorWest Community Health Centre, Dilico and other local health care providers. 

Together they:  

• Improved access to care and changed process, practice and behaviour through hiring an outreach support worker dedicated to vulnerably housed palliative care clients. 

• Built trusting relationships with vulnerably housed individuals using trauma-informed and culturally safer approaches to care. 

• Advocated for vulnerably housed clients within health and social services settings.  

The team played a vital role in reducing missed appointments, improving continuity of care, connecting clients promptly with primary care resulting in diverting unnecessary emergency department visits and improved timely access to palliative care that ensured vulnerably housed individuals received equitable and appropriate support. For staff, identifying and discussing clients’ experiences deepened their collective understanding and helped shape alternative, more responsive approaches to care and service delivery.

Université Laval is helping to improve palliative and end-of-life care through research, education and knowledge mobilization.

Project partners: Clinique SPOT; Direction du soutien à l’autonomie des personnes âgées, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale; Lauberivière; Centre d’hébergement autochtone de Québec; Direction de la qualité, de l’évaluation, de l’éthique et des affaires institutionnelles, CHU de Québec; Ministère de la Santé et des Services sociaux; and the Direction des soins infirmiers et responsable du dossier des soins palliatifs.

As part of this collaborative, Université Laval has helped to forge connections between individuals experiencing or at risk of homelessness, care providers and community organizations in the Quebec City area. The project aimed to better adapt palliative and end-of-life care to the lives and needs of these individuals. Among other efforts, Université Laval has provided training, supported a community of practice that brought together community, social and healthcare stakeholders, and facilitated the joint efforts needed to develop adapted initiatives.

This outreach, mobilization and joint action has yielded results since the start of the project. Numerous initiatives have been launched, and new long-term services have been developed, with funding from the public health system, to better meet the needs of people experiencing or at risk of homelessness.

Major impacts: Community capacity building: Participants from community, social and healthcare organizations felt better prepared, more comfortable openly discussing palliative and end-of-life care and better equipped to work with people experiencing or at risk of homelessness. This has made it easier for them to put their knowledge into action and facilitated the sustainable integration of new responses into public services.

Vancouver Coastal Health (VCH) and Providence Health Care (PHC) are responsible for the delivery of health services to the Downtown Eastside of Vancouver, a diverse community where many people experience homelessness and/or precarious housing, substance use and/or mental health challenges, and multiple other structural vulnerabilities. 

For this initiative VCH and PHC collaborated with a number of agencies including Peer Operations/Overdose Emergency Response Team, VCH Indigenous Health, VCH Regional Mental Health/Substance Use, First Nations Health Authority and the BC Centre for Substance Use. 

Throughout the collaborative, their focus was on learning from people with lived and living experience of health and social inequities, as well as from frontline carers, peer support, housing workers and other outreach roles.  

The VCH and PHC initiative highlighted the valuable but often unrecognized role of housing, social care and community workers in supporting a palliative approach with the people they serve and the importance of empowering their voices within a more broadly defined care team. 

The team successfully drafted and is conducting ongoing evaluation of a conversation guide and form for understanding people’s wishes for care. This resource will support frontline workers in more focused advance care planning (ACP) conversations and - through a new process to have external documents uploaded into the electronic health record - ensure these ACP preferences are known during future hospital admissions. 

Victoria Cool Aid Society works with partners to offer life-changing services to adults impacted by poverty, colonization, stigma and homelessness. These services include transitional, recovery and permanent housing, emergency shelters, health and dental care including pharmacy services, employment assistance, and social and recreational opportunities. For the collaborative, Victoria Cool Aid Society partnered with Island Health’s Palliative & End-of-Life Care program and the Palliative Approaches to Care in Aging and Community Health team at the University of Victoria.  

Building on foundational learnings from Island Health’s Palliative Outreach Resource Team, the team engaged community members and partners to co-design a shared vision of palliative care services for the greater Victoria area. 

Through the collaborative, the team co-designed a shelter-based end-of-life program framework grounded in harm reduction, trauma-informed practices, cultural safety and autonomy. Staff engagement and learning sessions were foundational in the work and have helped establish new partnerships and strengthen existing ones.  

The initiative highlighted the importance of cross-sector collaboration, providing a clearer understanding of implementation requirements and advancing readiness for future implementation, while creating a transferable resource for other communities. 

The Winnipeg Regional Health Authority provides healthcare services to residents of the city of Winnipeg and some immediate surrounding municipalities.  WRHA community outreach groups, palliative care, Indigenous Health and other non-WRHA housing and outreach groups, along with George and Fay Yee Centre for Health Innovation and Shared Health, worked together to assess the need and possible responses to improving equity in access to palliative care for persons who were unhoused. 

Together the team: 

• Offered and participated in several Lunch and Listen events to better understand each others current practices in supporting a palliative approach to care, as well as gaps in services and connections. This also helped to launch relationships.  

• Engaged the community and hosted symposiums focusing on strengths, collaboration and inclusion while building relationships and encouraging innovation and creativity. 

• Created visual tools, a low barrier referral form and videos to improve access to care.  

• Created a new low-barrier palliative care consult team with modified criteria for access and engagement—the Community Outreach for a Mobile Palliative Approach and Support Service (COMPASS).

• Worked with Emergency Care Social Workers to develop a process for Emergency Continuity Care Plans to serve as a communication tool for those presenting to the Emergency Department for support, this creating an added opportunity for connection with COMPASS. 

The symposiums and working groups created opportunities to build awareness, education and coordination. Community engagement strengthened relationships and created buy-in and support to improve access to care for structurally vulnerable members of the community.