Palliative Care Integration into Primary Care

DSRIP Project Title: Integration of Palliative Care into Patient-Centered Medical Home Model (Project 3.g.i.)

Alliance staff contact: Carol Ann Tiberia | 518.701.2282


The project aims to help all providers to explicitly ask patients and their families what matters most to them, and ensure that this information is recorded, made available in the medical record, and actively used by all involved parties in decision making about care. It also aims to increase access to high-quality palliative care services for all people with serious illness, regardless of age, stage of disease, or care setting by training more clinicians to provide these services.

Why does the community need this project?

Palliative care is misunderstood and much needed.  A better understanding of palliative care results in helping more patients and families manage chronic or serious illnesses, improving quality of life.

Project Goal

Increase access to palliative care interventions for patients with the greatest need, determined by surveys designed to gauge a patient’s full spectrum of medical, psychosocial, behavioral health and other care needs.

Our Plan

  • Develop partnerships between providers and community based organizations to collaborate with primary care practices to support integration of palliative care services.
  • Train providers, consumers and the healthcare community to increase understanding and competence in palliative care.
  • Train clinicians (doctors, nurses, social workers, and others) receive basic training and ideally, certification in pain and symptom management, communication, and coordination of care across time and settings.
  • Engage managed care organizations to explore and ensure palliative care services reimbursement.