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.
Created by the University of Edinburgh to identify patients with unmet palliative care needs in both hospital and office settings.
General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.
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.
Created by the University of Edinburgh to identify patients with unmet palliative care needs in both hospital and office settings.
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.
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.
Presentation examining criteria for palliative care services.
Identifying the population in need of palliative care, and working with patients and treating clinicians for effective relationships. Includes suggested phone scripts.
An analysis highlighting that death and spending in the last year of life remains unpredictable despite many algorithms (Einav et al.).
A document with guidance and sample orders to assist nursing homes in identifying patients and residents with limited prognoses. INTERACT II.
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.).
General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.
Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.
Identifying the population in need of palliative care, and working with patients and treating clinicians for effective relationships. Includes suggested phone scripts.
Integration of a patient-reported symptom assessment tool into the EHR and workflow. CAPC and the Accountable Care Learning Collaborative.
Poster summarizing factors used to identify palliative need immediately after hospitalization, when the opportunity to prevent unnecessary utilization is highest. OHSU and Brown University.
NIH's code sets that can be used to create identification algorithms. See Advanced Illness and Frailty value sets, stewarded by NCQA.
Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.
Sample recruiter-patient audio exchange.
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.
Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.
Recommended assessment questions to typify pain and inform pain management for patients with serious illness.
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.
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 Medicin…
