Request for information about your outpatient palliative care program

The IPAL-OP National Advisory Board is seeking information from palliative care programs that provide outpatient services.

We are interested in gathering information from programs providing the following types of outpatient (non-acute care hospital) services:
• Clinic Practice
• Home-based/Home Visit Practice
• Long-term Care (LTC) or Assisted Living (AL) Practice
• Long-term Acute Care Hospital (LTAC) practice

We would like to use this information in order to...

• post your questionnaire online for others to learn from; and if you agree, enable others to contact you for peer to peer learning about your program.
• provide information to the IPAL-OP Advisory Board on trends in outpatient services, to support development of new technical assistance resources.

The questionnaire will take just a few moments to complete.

Thank you!!
IPAL-OP Advisory Board

(Please contact if you experience any technical difficulties)

* 1. Identifying information:

* 2. Check which program type you are reporting (check all that apply):

* 3. Tell us what is distinctive about your program which you would like to share with others (examples might include staffing, volume, patient population, funding, measurement, administrative or community relationships). [50-100 words]

* 4. Can you describe the single most challenging issue with which your program is struggling? (25-50 words)

* 5. Would you be willing to be contacted by individuals wishing to learn more about your program? If yes, please provide your contact information.

* 6. In order to help other IPAL-OP users, we would like to share selected questionnaire responses on the IPAL-OP website. By clicking this button, you give permission to have your questionnaire responses posted on the IPAL-OP website.