Patient Identification and Assessment

Checklist of triggers for referral to a specialty palliative care team.

Randomized controlled trial of a default palliative care order, with clinician opt-out ability, and its impact on patient care.

Descriptive study on the benefits of using a standardized screening tool to generate automatic referrals for palliative care consultation.

Used to identify patients at high risk for readmission or death.

Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.

Online tool that predicts risk of death within one year of hospitalization, specific to patients aged 70+.

Population health entities can use this list to proactively identify people with potentially unmet palliative care needs. Additional screening will be necessary.

Development of the NECPAL tool and preliminary prevalence rates in Catalonia. Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, et al. BMJ Supportive and Palliative Care, 2013.

Using claims data to identify the population in need of palliative care. Kelley AS and Bollens-Lund E, Journal of Palliative Medicine, 2017.

An analysis highlighting that death and spending in the last year of life remains unpredictable despite many algorithms (Einav et al.).

Guidance on how to gather culturally-relevant information from patients and families. Kagawa-Singer and Blackhall.

Best practices in how to use data sources, such as claims or medical records, to identify patients who are most likely to benefit from palliative care.

Population health entities can use this list to proactively identify people with potentially unmet palliative care needs. Additional screening will be necessary.

Using claims data to identify the population in need of palliative care. Kelley AS and Bollens-Lund E, Journal of Palliative Medicine, 2017.

An analysis highlighting that death and spending in the last year of life remains unpredictable despite many algorithms (Einav et al.).

Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.

Guidance on how to gather culturally-relevant information from patients and families. Kagawa-Singer and Blackhall.

Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.

Validated instrument to assess pain intensity and impact on function over time.

Measures the frequency, severity, and distress associated with 32 symptoms.

Assessment of more than 30 symptoms; also quantifies severity.

Assessment tool for symptom burden and impact on quality of life. National Comprehensive Cancer Network (NCCN), 2016.

Brief (4-question) screening tool for anxiety and depression.

Used to screen, diagnose and measure the severity of depression.

Assesses the patient's functional abilities including ambulation, activity level, self-care ability, intake and consciousness.

Stratifies patients by level of functional ability. Like the PPS, the Karnofsky score can be used to predict survival.

Assess disease progression, impact on activities of daily living, and appropriate treatment and prognosis.

Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.

Self-reported caregiver assessment.

Modular approach to measuring health-related quality of life in both healthy children and those with acute and chronic health conditions.

Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.

Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model, and recommended for Medicare and Medicaid beneficiaries.

Instrumental Activities of Daily Living (IADLs) span everyday tasks that many people with serious illness have difficulty with. This assessment tool will help teams identify needs that can be addressed with community supports

The goal of this learning activity is to equip clinicians across all disciplines with the tools to foster effective and inviting clinical encounters with seriously ill patients.

This learning activity, Practicing Inclusive Clinical Encounters, will help clinicians integrate strategies for effective and inclusive clinical encounters into their daily practice.

Assessment tool and resource list to address social risk factors.

Social needs screen including: social needs domains, best practices, recommended screening tool (in English and Spanish) and a library of clinically-validated and patient-centered questions.

With social determinants of health (SDOH) being closely linked to health outcomes among populations historically exposed to health care disparities, the Ascension team is addressing barriers and needs of community members through the implementation of a systematic SDOH screening and resource referral process.

Website for patients and families with definitions, relevant patient stories, resources, and a searchable database to find palliative care programs.