Patient Identification and Assessment
Patients and families living with serious illness have a range of needs beyond disease treatment, including support for functional limitation, pain and other symptoms, and caregiver burden.
Use this toolkit to establish criteria for finding the right patients at the right time and assessing their physical, functional, emotional, social, and spiritual needs.
What’s in the Toolkit
For Inpatient Providers
Target scarce resources to the patients most in need by developing appropriate referral criteria and building consult triggers into the electronic health record (EHR). Includes adult and pediatric referral criteria for inpatient palliative care.
Checklist of triggers for referral to a specialty palliative care team.
Guidance on needs assessment, screening criteria selection, implementation planning, and evaluation.
General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.
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.
For Community-Based Providers
Identifying patients in community settings is particularly challenging because functional/cognition status is rarely captured in claims or clinical data systems. Use this toolkit to find the population at risk for readmission, poor outcomes, preventable suffering, or mortality.
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.
Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.
Using claims data to identify the population in need of palliative care. Kelley AS and Bollens-Lund E, Journal of Palliative Medicine, 2017.
Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.
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.
For Systems, Plans, and Accountable Care Organizations
Guidance and case studies to find the right patients at the right time.
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.
Integration of a patient-reported symptom assessment tool into the EHR and workflow. CAPC and the Accountable Care Learning Collaborative.
Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.
Guidance on how to gather culturally-relevant information from patients and families. Kagawa-Singer and Blackhall.
Clinical Assessment Tools
Evidence-based resources for assessing pain, symptom burden, psychological and social needs, caregiver burden, and spiritual distress.
Addressing the physical, psychological, and social impacts of serious illness, as well as the functioning of a healthy interdisciplinary team.
Screening for Social Needs
These resources can help teams highlight social needs such as unsafe housing or food insecurity
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.
Information for Patients about Palliative Care
Help patients and families understand palliative care and request a consult when needed.
Website for patients and families with definitions, relevant patient stories, resources, and a searchable database to find palliative care programs.
Faculty
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Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Allison Silvers, MBA
Chief Health Care Transformation Officer
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Dana Lustbader, MD, FAAHPM
Regional Medical Officer, Landmark Health, OPTUM
Professor of Critical Care & Palliative Medicine, Z…
Includes 40 resources:
- Comprehensive Guidance
- Population Identification and Assessment
- Specialty Palliative Care Services and Benefits
- Provider Network Strategies
- The Role of Care Managers
- Case Studies
Includes 22 resources:
- Defining Palliative Care
- Palliative Care Value Across Settings
- Calculators, Templates, and Case Studies
Includes 27 resources:
- The Case for Communication and Symptom Management Training
- Clinical Training Recommendations for All Clinicians Caring for Patients with Serious Illness
- Implementing a Training Program
- Resources for Reinforcing Skills
- Case Studies and Additional Resources