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.

CAPC Workshop Materials: Recruitment and Retention Quick Tips Summary
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A summary of the practical tips and strategies related to recruitment and retention from CAPC's workshop session.

Quick Tips #1: Hiring New Team Members
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Hire a stable, high-performing team. Center to Advance Palliative Care, 2018.

Improving Team Effectiveness: Hiring and Onboarding

Watch this CAPC on-demand webinar, Improving Team Effectiveness: Hiring and Onboarding. Find more webinars at capc.org

Quick Tips #2: Onboarding New Team Members
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Best practices for onboarding new staff to the palliative care team. Center to Advance Palliative Care, 2018.

CAPC Curriculum - Continuing Education Credits Overview

Course catalog for CAPC's clinical training curriculum. All courses provide continuing education credits for physicians, nurses, social workers, and care managers from all specialties and are free for CAPC members.

Fast Facts and Concepts

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.

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

Art Therapist
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Bereavement Coordinator (Pediatrics)
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Care Coordinator (Adult)
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Shared by Mount Carmel.

Case Manager (Pediatrics)
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Chaplain (Adult)
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Chaplain (Pediatrics)
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Child Life Specialist (Pediatrics)
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Shared by University of California San Francisco.

Clinic Administrative - Secretarial
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Clinical Social Worker, LCSW (Adult)
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Shared by UVA Medical Center.

Consulting Physician (Adult)
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Consulting Physician (Pediatrics)
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Shared by University of California San Francisco.

Massage Therapist (Adult)
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Shared by Fairview Health Services.

Music Therapist
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Nurse Practitioner Job Description and Performance Appraisal
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Palliative Care Lead APRN (Adult)
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Shared by Mount Carmel.

Palliative Care Medical Director
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Physician (Pediatrics)
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Program Director (Pediatrics)
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Shared by University of California San Francisco.

Registered Case Manager (Pediatrics)
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Registered Nurse (Adult)
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Registered Nurse (Pediatrics)
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Registered Nurse- Clinic (Adult)
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Shared by Massachusetts General Hospital.

RN (Pediatrics)
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RN Care Coordinator 2 (Adult)
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Shared by UVA Medical Center.

RN Care Coordinator 3 (Adult)
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Shared by UVA Medical Center.

RN Case Manager (Adult)
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Shared by Mount Carmel.

Social Worker (Pediatrics)
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Shared by University of California San Francisco.

Social Worker, LICSW (Adult)
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Shared by Mount Carmel.

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

Improving Team Effectiveness and Resilience

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.

Quick Tips #5: Running Effective Interdisciplinary Team Patient Care Meetings
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Best practices in efficient, effective IDT meetings.

Leading a Patient and Caregiver Meeting

Learn to effectively lead meetings that help patients and caregivers become aligned around the patient’s goals.

Optimizing Billing Practices

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

CAPC Measurement Guide
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Recommendations for measures and approaches to evaluating palliative care services that enable growth and improvement.

Improving Team Performance

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

Clinical Rounding Tool
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Sample clinical rounding tool. CAPC.

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

Role Clarity for a Highly Effective Interdisciplinary Team
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Clarify team roles and responsibilities to ensure positive relationships and productivity.

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

Webinar presentation.

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.

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

Watch this CAPC on-demand webinar, Improving Team Effectiveness: A Virtual Case Conference on Building and Sustaining High Performing Teams.

Quick Tips Summary: Integrating Spiritual Care as Part of Interdisciplinary, Quality Palliative Care
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A summary of tips and suggestions for integrating spiritual care on the palliative care team, from CAPC's virtual workshop.

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.

How Providing Feedback Helps to Build Team Connection and Trust

In this on-demand webinar, Donna Stevens, MHA, and a panel of palliative care leaders will explore the benefits of consistent, honest feedback offered in different formats.

Becoming Aware of Our Emotional Reactions to Improve Clinical Practice

This session covers how conscious and unconscious reactions impact communication with patients and families, and offers techniques to improve self-awareness and personal resilience.

Working Smarter Together: Interdisciplinary Collaboration in Outpatient Palliative Care

In this on-demand Master Clinician session, speakers describe three different outpatient palliative care models, and share strategies to maximize team productivity and collaboration in outpatient palliative care clinics.

Managing Expectations in Uncertainty

This on-demand Master Clinician session will present and illustrate a systematic, case-based approach to managing expectations during times of uncertainty.

Team Health and Resilience
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Ensure strong morale and healthy team functioning.

Improving Team Effectiveness: Team Health and Resilience

Watch this CAPC on-demand webinar, Improving Team Effectiveness: Team Health and Resilience. Find more webinars at capc.org

Strategies for Maximizing the Health/Wellness of Palliative Care Teams

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

Case Reviews

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

Palliative Care Team Wellness Assessment Worksheet
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Identify obstacles to team wellness and resources to support healthy functioning.

Improving Team Effectiveness: Team Communication

Watch this CAPC on-demand webinar, Improving Team Effectiveness: Team Communication. Find more webinars at capc.org.

Ensuring that appropriate patients are systematically referred to palliative care.

CAPC Palliative Care Referral Criteria

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

Identifying the Right Patients for Specialty Palliative Care

Presentation examining criteria for palliative care services.

Implementing ICU Screening Criteria for Unmet Palliative Care Needs: A Guide for ICU and Palliative Care Staff
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Guidance on needs assessment, screening criteria selection, implementation planning, and evaluation.

Communicating with Treating Clinicians about the Implications of Frailty
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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

Webinar on building assessment and trigger protocols into the EHR.

Pediatric Palliative Care Referral Criteria
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General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.

Charlson Comorbidity Index

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

LACE Index Scoring Tool

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

Walter Prognostic Index

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

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.

Referring Health Care Provider Survey
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Assess referral processes and referrer satisfaction.

Consult Etiquette: Communicating with Referring Providers

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

CAPC Tutorial: Consult Etiquette
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Self-study tutorial on improving referrer relationships.

Toolkit to support strategic planning, team leadership, and professional development for the palliative care leader. Includes 30 resources.
Strategic planning for program growth, including making the case, demonstrating value, and strengthening relationships with partners. Includes 22 resources.

See all 49 Toolkits

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