Designing a Home-Based Palliative Care Program
Patients are living longer with serious illness, and their care is moving out of the hospital and into community care settings. For the sickest patients, this means care delivered in the home. Practices participating in the Serious Illness Population (SIP) option under CMMI’s Primary Care First initiative can especially benefit from these tools.
This toolkit was developed by the CAPC Home-Based Palliative Care Workgroup. We thank the eleven members of the workgroup for contributing their expertise and program materials.
Workgroup Chair:
Donna Stevens, MHA, Program Director, OACIS/Palliative Medicine, Lehigh Valley Health Network, Allentown, PA, representing the OACIS/Palliative Care Home-Based Consult Service.
Download a full listing of participants and programs in the CAPC Home-Based Palliative Care Workgroup. For program profiles, see Palliative Care in the Home: A Guide to Program Design.
What’s in the Toolkit
Needs Assessment
Engage stakeholders—patients and families, organizational leadership, referrers, and financial partners—to guide program design that is aligned with their priorities.
The National Consensus Project (NCP) Clinical Practice Guidelines are the national standard for high quality palliative care. National Consensus Project for Quality Palliative Care, 2018.
The majority of people with serious illness are neither dying nor hospitalized. So, palliative care needs to be available in all settings outside hospitals—in medical offices and clinics, in post-acute and long-term care facilities, and in patient homes. This publication includes key data on the value of community palliative care, program profiles, and a case example to use with leadership.
Defining community-based palliative care: which patients need it, how it is delivered, and how it differs from inpatient palliative care.
Evaluating patient need, service requirements, care settings, and stakeholder priorities for the community-based palliative care program.
Step-by-step tool to evaluate patient need, stakeholder priorities, organizational readiness, and sites of care for a new or growing community-based palliative care service.
Comprehensive instructions and tools for conducting focus groups during a needs assessment. Published by Community Tool Box.
In this Virtual Office Hour, ask questions of expert faculty about launching a new community-based program, designing your service package and staffing, and navigating the challenges of a new program.
Program Design
Home-based palliative care models are designed to match patient need, organizational priorities, and referrer relationships.
Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.
Translating needs assessment into service design for the community-based palliative care program.
Staffing models and benchmarks used by home-based programs.
Establishing referral partnerships to address gaps in care for palliative care patients.
Palliative Care Leadership Centers (PCLC) offer hospitals two days of in-person, customized operational training and one year of mentoring.
Shared by ProHEALTH Care Support.
Shared by Interim HealthCare/CarePoint, 2017
Shared by Sutter Health-Advanced Illness Management (AIM).
Staffing models and benchmarks used by home-based programs.
Key components of telehealth service delivery, especially in a home-based palliative care program.
Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.
Business Planning and Program Financing
Tools to design a sustainable business plan and budget for your home-based program.
Building a budget and a business plan for the community-based program. Includes business planning tools.
Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.
Tools for translating operational and service decisions into a realistic budget and business plan.
For Hospice-Led Programs
Many hospices offer palliative care as a separate business line. Use these tools to navigate palliative care program start-up and operations.
Designing high-quality, sustainable palliative care as a separate business line.
In this Virtual Office Hour, ask questions about operating a community-based palliative care program under your hospice organization, including referrals across service lines, financing strategies, and how to communicate your service lines to patients.
Considerations for the hospice before starting a non-hospice palliative care service line. Webinar presentation.
Differentiating hospice and palliative care services and eligibility. Webinar presentation.
Assists hospices operating community palliative care programs to understand five key steps to take before launching their program. Center to Advance Palliative Care, 2019.
Checklist for assessing organizational capacity to launch a non-hospice palliative care service. Center to Advance Palliative Care, 2019.
Guidance for clarifying boundaries between hospice and palliative care services, and building internal cohesion. Center to Advance Palliative Care, 2019.
Program design considerations including patients, services, and staff. Center to Advance Palliative Care, 2019.
Measurement Tools
It is essential to collect data that matter to program stakeholders—including patients—and that facilitate continuous quality improvement. Use these tools to identify measures, collect data, and use your data to demonstrate program value.
Use this toolkit to select program measures that demonstrate value to stakeholders and support quality care delivery. Overcome common measurement obstacles and synthesize program data.
Excerpted from the Guide to Home-Based Program Design. Center to Advance Palliative Care, 2017.
Recommendations for measures and approaches to evaluating palliative care services that enable growth and improvement.
Referrals, Screening, and Patient Assessment
Identify appropriate patients for your program, and assess their palliative care needs.
Toolkit for finding the right patients at the right time to address gaps in care.
Guidance on dosing interventions allocating visit frequency based on patient risk.
Shared by Sutter Health-Advanced Illness Management (AIM).
For referrers. Shared by OACIS/ Lehigh Valley Health Network.
For referrers. Shared by Optio Health Services.
Shared by ProHEALTH Care Support.
Sample Policies and Procedures
Protocols used by home-based programs to standardize team practice.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by ProHEATH Care Support.
Program Marketing
Sample materials to explain program benefits and services to patients, families, and referrers.
Shared by ProHEATH Care Support.
Shared by ProHEATH Care Support.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
On the benefits of partnering with the palliative care program. Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by OACIS/Lehigh Valley Health Network.
Shared by Sutter Health-Advanced Illness Management (AIM).
Sample brochure shared by Hospice of Buffalo.
Shared by ProHEALTH Care Support.
Shared by Optio Health Services.
Staffing Resources
Tools to support team development and sample job descriptions for a home-based program.
Staffing models and benchmarks used by home-based programs.
Hire and onboard your staff, manage program operations, and ensure a healthy high-functioning team using this toolkit.
Shared by ProHEALTH Care Support.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Sutter Health-Advanced Illness Management (AIM).
Sample job description for role to assist with coordination between "usual care" and the palliative care team, especially during transitions. Shared by Interim HealthCare/CarePoint.
Shared by Meridian Health.
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by Sutter Health-Advanced Illness Management (AIM).
Presentation on role clarity in the home-based palliative care IDT.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by OACIS/Lehigh Valley Health Network.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by ProHEALTH Care Support.
Telehealth
Home-based palliative care program efficiency depends upon balancing the need for patient contact with drive times. Many programs use telehealth to maintain contact with patients when home visits are not required, in order to enable program growth and scale.
Key components of telehealth service delivery, especially in a home-based palliative care program.
Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.
Provides a review of the current evidence for telepalliative care and potential applications and practical tips for using the technology.
Tools for the Home Visit
Working in the home can be unpredictable. Use these tools to ensure safe, respectful interactions in patients’ homes.
Shared by ProHEALTH Care Support.
Excerpted from the Guide to Palliative Care in the Home.
Shared by ProHEALTH Care Support.
Sample opioid treatment agreement.
Institute for Healthcare Improvement, August 2017.
Faculty
-
Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Jeanne Sheils Twohig, MPA
Consultant
Center to Advance Palliative Care -
Donna W. Stevens, MHA
Partner
Leaderly Consultants -
Brynn Bowman, MPA
Chief Executive Officer, Center to Advance Palliative Care
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Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Consultant
Center to Advance Palliative Care
