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.

Quick Tips #1: Hiring New Team Members
MEMBERS ONLY locked

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

Improving Team Effectiveness: Hiring and Onboarding
Quick Tips #2: Onboarding New Team Members
MEMBERS ONLY locked

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. 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.

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
MEMBERS ONLY locked
Clinic Administrative - Secretarial
MEMBERS ONLY locked
Music Therapist
MEMBERS ONLY locked
Palliative Care Medical Director
MEMBERS ONLY locked
Nurse Practitioner Job Description and Performance Appraisal
MEMBERS ONLY locked
Care Coordinator (Adult)
MEMBERS ONLY locked

Shared by Mount Carmel.

Registered Nurse- Clinic (Adult)
MEMBERS ONLY locked

Shared by Massachusetts General Hospital.

Massage Therapist (Adult)
MEMBERS ONLY locked

Shared by Fairview Health Services.

Registered Nurse (Adult)
MEMBERS ONLY locked
Palliative Care Lead APRN (Adult)
MEMBERS ONLY locked

Shared by Mount Carmel.

RN Care Coordinator 2 (Adult)
MEMBERS ONLY locked

Shared by UVA Medical Center.

RN Care Coordinator 3 (Adult)
MEMBERS ONLY locked

Shared by UVA Medical Center.

Social Worker, LICSW (Adult)
MEMBERS ONLY locked

Shared by Mount Carmel.

Clinical Social Worker, LCSW (Adult)
MEMBERS ONLY locked

Shared by UVA Medical Center.

Consulting Physician (Adult)
MEMBERS ONLY locked
RN Case Manager (Adult)
MEMBERS ONLY locked

Shared by Mount Carmel.

Chaplain (Adult)
MEMBERS ONLY locked
RN (Pediatrics)
MEMBERS ONLY locked
Registered Nurse (Pediatrics)
MEMBERS ONLY locked
Physician (Pediatrics)
MEMBERS ONLY locked
Social Worker (Pediatrics)
MEMBERS ONLY locked

Shared by University of California San Francisco.

Registered Case Manager (Pediatrics)
MEMBERS ONLY locked
Case Manager (Pediatrics)
MEMBERS ONLY locked
Program Director (Pediatrics)
MEMBERS ONLY locked

Shared by University of California San Francisco.

Child Life Specialist (Pediatrics)
MEMBERS ONLY locked

Shared by University of California San Francisco.

Chaplain (Pediatrics)
MEMBERS ONLY locked

Shared by University of California San Francisco.

Consulting Physician (Pediatrics)
MEMBERS ONLY locked

Shared by University of California San Francisco.

Bereavement Coordinator (Pediatrics)
MEMBERS ONLY locked

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.

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

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

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

Webinar presentation.

Daily Team Meetings: Triage System

Guidelines for effective team meeting management.

Conducting a Family Meeting

Communication techniques for an effective family meeting.

Optimizing Billing Practices

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

Recommended Program Measures and CAPC Measurement Toolkit
MEMBERS ONLY locked

Recommended measures for inpatient and community palliative care programs, and using data to demonstrate value and perform continuous quality 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
MEMBERS ONLY locked

Sample clinical rounding tool. CAPC.

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

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

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

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.

I Don't Know What It Is You Do: The Role and Scope of the Chaplain on the Palliative Care Team
Improving Team Effectiveness: A Virtual Case Conference on Building and Sustaining High Performing Teams

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.

Quick Tips #3: Team Health and Resilience
MEMBERS ONLY locked

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

Improving Team Effectiveness: Team Health and Resilience
Strategies for Maximizing the Health/Wellness of Palliative Care Teams

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

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

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.

Palliative Care Team Wellness Assessment Worksheet
MEMBERS ONLY locked

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

Improving Team Effectiveness: Team Communication

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
MEMBERS ONLY locked

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

Communicating with Treating Clinicians about the Implications of Frailty
MEMBERS ONLY locked

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
MEMBERS ONLY locked

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

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
MEMBERS ONLY locked

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
MEMBERS ONLY locked

Self-study tutorial on improving referrer relationships.