Building and Supporting Effective Palliative Care Teams

Last Reviewed: March 4, 2019

Strong team management can determine whether the palliative care program succeeds in its mission and operates within budget—and the first step is to build an effective palliative care team. In addition to meeting quality standards and providing interdisciplinary care, your staffing plan and team protocols must reflect your patient population, organizational culture, and financial environment.

Given that the specialty palliative care workforce is limited, hiring and retaining strong staff is critical. Use this toolkit to make decisions about team staffing, program operations, and healthy team functioning.

What’s in the Toolkit

Hiring and onboarding methods to ensure strong team culture and clinical standardization.

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Quick Tips #1: Hiring New Team Members

Last Updated: January 29, 2019

Hire a stable, high-performing team. Center to Advance Palliative Care, 2018.

Improving Team Effectiveness: Hiring and Onboarding

Last Updated: January 23, 2020

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Quick Tips #2: Onboarding New Team Members

Last Updated: January 29, 2019

Best practices for onboarding new staff to the palliative care team. Center to Advance Palliative Care, 2018.

CAPC Curriculum - Continuing Education Credits Overview

Last Updated: March 31, 2020

Course catalog for CAPC's clinical training curriculum. Onboard new palliative care team members using standardized training, or train non-palliative care specialists in core skills. All courses provide continuing education credits for all disciplines and are free for CAPC members.

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Fast Facts and Concepts

Last Updated: January 29, 2019

Concise, practical, peer-reviewed and evidence-based summaries on topics important to clinicians and trainees caring for seriously ill patients. Use Fast Facts to onboard staff and for ongoing team education.

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A catalog of palliative care position descriptions that can be modified for use with new hires.

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Art Therapist

Last Updated: March 4, 2019

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Clinic Administrative - Secretarial

Last Updated: March 4, 2019

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Music Therapist

Last Updated: March 4, 2019

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Palliative Care Medical Director

Last Updated: March 4, 2019

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Nurse Practitioner Job Description and Performance Appraisal

Last Updated: February 3, 2019

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Care Coordinator (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

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Registered Nurse- Clinic (Adult)

Last Updated: March 4, 2019

Shared by Massachusetts General Hospital.

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Massage Therapist (Adult)

Last Updated: March 4, 2019

Shared by Fairview Health Services.

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Registered Nurse (Adult)

Last Updated: March 4, 2019

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Palliative Care Lead APRN (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

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RN Care Coordinator 2 (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

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RN Care Coordinator 3 (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

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Social Worker, LICSW (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

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Clinical Social Worker, LCSW (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

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Consulting Physician (Adult)

Last Updated: March 4, 2019

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RN Case Manager (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

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Chaplain (Adult)

Last Updated: March 4, 2019

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RN (Pediatrics)

Last Updated: March 4, 2019

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Registered Nurse (Pediatrics)

Last Updated: March 4, 2019

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Physician (Pediatrics)

Last Updated: March 4, 2019

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Social Worker (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

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Registered Case Manager (Pediatrics)

Last Updated: March 4, 2019

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Case Manager (Pediatrics)

Last Updated: March 4, 2019

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Program Director (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

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Child Life Specialist (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

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Chaplain (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

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Consulting Physician (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

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Bereavement Coordinator (Pediatrics)

Last Updated: March 4, 2019

Tools and strategies for managers to promote efficient teamwork, strong communication, and quality care.

Improving Team Effectiveness

Part of the Improving Team Effectiveness series, this session covers building and sustaining a stable, effective interdisciplinary team. Ask questions on topics such as hiring and onboarding, role clarity, team communication, and preventing burnout.

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Quick Tips #5: Running Effective Interdisciplinary Team Patient Care Meetings

Last Updated: February 3, 2019

Best practices in efficient, effective IDT meetings. Center to Advance Palliative Care, 2018.

Improving Team Effectiveness: Running Effective Interdisciplinary Team (IDT) Meetings

Last Updated: August 6, 2019

Webinar presentation.

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Daily Team Meetings: Triage System

Last Updated: March 17, 2020

Guidelines for effective team meeting management.

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Conducting a Family Meeting

Last Updated: March 30, 2020

Communication techniques for an effective family meeting.

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Optimizing Billing Practices

Last Updated: March 4, 2019

Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.

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Recommended Program Measures and CAPC Measurement Toolkit

Last Updated: February 3, 2019

Recommended measures for inpatient and community palliative care programs, and using data to demonstrate value and perform continuous quality improvement.

Improving Team Performance

Last Updated: January 15, 2015

Strategic planning for new or veteran programs, and a framework for identification of barriers to team efficiency and team health.

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Clinical Rounding Tool

Last Updated: May 18, 2020

Sample clinical rounding tool. CAPC.

Clarifying team roles and responsibilities on the interdisciplinary team to ensure positive relationships and productivity.

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Quick Tips #4: Role Clarity for a Highly Effective Interdisciplinary Team

Last Updated: January 23, 2020

Clarify team roles and responsibilities to ensure positive relationships and productivity. Center to Advance Palliative Care, 2018.

Improving Team Effectiveness: Role Clarity for a Highly Effective Interdisciplinary Team

Last Updated: August 6, 2019

Webinar presentation.

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Role of the Social Worker on the Interdisciplinary Team

Ask questions about the role of the social worker on the palliative care team, including distinguishing the role from other disciplines on the team and navigating competing demands on palliative care social workers from the social work department.

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I Don't Know What It Is You Do: The Role and Scope of the Chaplain on the Palliative Care Team

Last Updated: August 11, 2019

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Improving Team Effectiveness: A Virtual Case Conference on Building and Sustaining High Performing Teams

Last Updated: August 11, 2019

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Healthy palliative care teams are a product of strong leadership, clear roles and responsibilities, and attention to team well-being and dynamics. Use the resources below to assess and strengthen team wellness in support of staff retention and effectiveness.

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Quick Tips #3: Team Health and Resilience

Last Updated: February 3, 2019

Ensure strong morale and healthy team functioning. Center to Advance Palliative Care, 2018.

Improving Team Effectiveness: Team Health and Resilience

Last Updated: August 11, 2019

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Strategies for Maximizing the Health/Wellness of Palliative Care Teams

Last Updated: January 29, 2019

Monograph on processes that promote team health. Center to Advance Palliative Care, 2014.

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Improving Team Effectiveness Case Reviews: A Virtual Case Conference on Burnout and Team Health

Last Updated: August 6, 2019

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Case Reviews

Last Updated: February 14, 2020

CAPC Master Clinician case reviews of complex patient cases cover topics such as pain management, family dynamics, service partnerships, disease-specific care, spiritual care, and more.

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Palliative Care Team Wellness Assessment Worksheet

Last Updated: February 3, 2019

Identify obstacles to team wellness and resources to support healthy functioning.

Improving Team Effectiveness: Team Communication

Last Updated: August 11, 2019

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Ensuring that appropriate patients are systematically referred to palliative care.

CAPC Palliative Care Referral Criteria

Last Updated: April 15, 2020

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

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Identifying the Right Patients for Specialty Palliative Care

Last Updated: August 11, 2019

Presentation examining criteria for palliative care services.

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Implementing ICU Screening Criteria for Unmet Palliative Care Needs: A Guide for ICU and Palliative Care Staff

Last Updated: February 3, 2019

Guidance on needs assessment, screening criteria selection, implementation planning, and evaluation.

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Communicating with Treating Clinicians about the Implications of Frailty

Last Updated: February 3, 2019

Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.

EHR Strategies for the Palliative Care Team: A Town Hall Discussion

Last Updated: August 11, 2019

Webinar on building assessment and trigger protocols into the EHR.

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Pediatric Palliative Care Referral Criteria

Last Updated: February 3, 2019

General referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses. Center to Advance Palliative Care, updated 2016.

Charlson Comorbidity Index

Last Updated: February 3, 2019

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

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LACE Index Scoring Tool

Last Updated: February 3, 2019

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

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Walter Prognostic Index

Last Updated: February 3, 2019

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

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Whether your palliative care consults are triggered based on standard clinical criteria or depend upon individual referrers, collaboration is necessary. Use these tools to build, evaluate, and improve relationships with referrers.

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Referring Health Care Provider Survey

Last Updated: February 3, 2019

Assess referral processes and referrer satisfaction.

Consult Etiquette: Communicating with Referring Providers

Last Updated: November 12, 2015

Guidance for palliative care teams to build collaborative relationships with referrers.

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CAPC Tutorial: Consult Etiquette

Last Updated: January 29, 2019

Self-study tutorial on improving referrer relationships.

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