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.

National Consensus Project for Quality Palliative Care, 4th edition

Last Updated: January 29, 2019

The National Consensus Project (NCP) Clinical Practice Guidelines are the national standard for high quality palliative care. National Consensus Project for Quality Palliative Care, 2018.

view
MEMBERS ONLY locked

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: August 11, 2019

watch
MEMBERS ONLY locked

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.

A Profile of Active Hospice and Palliative Medicine Physicians, 2016

Last Updated: February 23, 2019

This report provides a picture of the hospice and palliative medicine (HPM) workforce in the United States in 2016. Published by the American Academy of Hospice and Palliative Medicine and the Health Workforce Institute at George Washington University, March 2017.

view

The Role of the Advanced Practice Registered Nurse (APRN) in Community-Based Palliative Care

Last Updated: August 12, 2019

watch

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.

register

Find a Career in Palliative Care

Last Updated: February 7, 2019

Post a position or browse for palliative care jobs. CAPC membership not required for participation.

view

Specialty Palliative Care Certification

Last Updated: July 18, 2019

Information for clinicians of all disciplines on the process of becoming certified palliative care specialists.

view

CAPC Curriculum - Continuing Education Credits Overview

Last Updated: August 16, 2019

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.

download

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.

view

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

MEMBERS ONLY locked

Art Therapist

Last Updated: March 4, 2019

MEMBERS ONLY locked

Clinic Administrative - Secretarial

Last Updated: March 4, 2019

MEMBERS ONLY locked

Music Therapist

Last Updated: March 4, 2019

MEMBERS ONLY locked

Palliative Care Medical Director

Last Updated: March 4, 2019

MEMBERS ONLY locked

Nurse Practitioner Job Description and Performance Appraisal

Last Updated: February 3, 2019

MEMBERS ONLY locked

Care Coordinator (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

MEMBERS ONLY locked

Registered Nurse- Clinic (Adult)

Last Updated: March 4, 2019

Shared by Massachusetts General Hospital.

MEMBERS ONLY locked

Massage Therapist (Adult)

Last Updated: March 4, 2019

Shared by Fairview Health Services.

MEMBERS ONLY locked

Registered Nurse (Adult)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Palliative Care Lead APRN (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

MEMBERS ONLY locked

RN Care Coordinator 2 (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

MEMBERS ONLY locked

RN Care Coordinator 3 (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

MEMBERS ONLY locked

Social Worker, LICSW (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

MEMBERS ONLY locked

Clinical Social Worker, LCSW (Adult)

Last Updated: March 4, 2019

Shared by UVA Medical Center.

MEMBERS ONLY locked

Consulting Physician (Adult)

Last Updated: March 4, 2019

MEMBERS ONLY locked

RN Case Manager (Adult)

Last Updated: March 4, 2019

Shared by Mount Carmel.

MEMBERS ONLY locked

Chaplain (Adult)

Last Updated: March 4, 2019

MEMBERS ONLY locked

RN (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Registered Nurse (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Advanced Practice Nurse (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Physician (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Social Worker (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

MEMBERS ONLY locked

Registered Case Manager (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Case Manager (Pediatrics)

Last Updated: March 4, 2019

MEMBERS ONLY locked

Program Director (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

MEMBERS ONLY locked

Child Life Specialist (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

MEMBERS ONLY locked

Chaplain (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

MEMBERS ONLY locked

Consulting Physician (Pediatrics)

Last Updated: March 4, 2019

Shared by University of California San Francisco.

MEMBERS ONLY locked

Bereavement Coordinator (Pediatrics)

Last Updated: March 4, 2019

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

Leadership Skills in Palliative Care

Last Updated: March 4, 2019

Toolkit to support strategic planning, team leadership, and professional development for the palliative care leader.

view

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.

start the course
MEMBERS ONLY locked

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.

watch
MEMBERS ONLY locked

Daily Team Meetings: Triage System

Last Updated: February 23, 2019

Guidelines for effective team meeting management.

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.

view

Marketing to Increase Referrals

In this Virtual Office Hour, ask questions about how to promote your program, including advice for engaging stakeholders, understanding referral criteria, and using appropriate messaging for marketing palliative care services.

register

Measurement Best Practices

Last Updated: March 4, 2019

Use this toolkit to select program measures that demonstrate value to stakeholders and support quality care delivery. Overcome common measurement obstacles and synthesize program data.

view

Conducting a Family Meeting

Last Updated: January 15, 2015

Communication techniques for an effective family meeting.

start the course

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.

register

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.

Consult Etiquette: Communicating with Referring Providers

Last Updated: November 12, 2015

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

start the course
MEMBERS ONLY locked

Referring Health Care Provider Survey

Last Updated: February 3, 2019

Assess referral processes and referrer satisfaction.

MEMBERS ONLY locked

CAPC Tutorial: Consult Etiquette

Last Updated: January 29, 2019

Self-study tutorial on improving referrer relationships.

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.

MEMBERS ONLY locked

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

watch

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.

download

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

Last Updated: August 6, 2019

watch

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

Last Updated: August 11, 2019

watch
MEMBERS ONLY locked

Palliative Care Team Wellness Assessment Worksheet

Last Updated: February 3, 2019

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

Martyrs in Palliative Care

Last Updated: February 3, 2019

A 2011 article making the case for taking care of ourselves, in order to best serve patient, families, and our teams. Weissman DE, Journal of Palliative Medicine.

view
MEMBERS ONLY locked

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

Last Updated: February 3, 2019

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.

watch

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

watch

Improving Team Effectiveness: Team Communication

Last Updated: August 11, 2019

watch

IDT strategies to support patients, families, and clinical teams through complex cases.

Master Clinician Series

Last Updated: March 3, 2019

Presentation of complex patient cases by an interdisciplinary faculty, followed by group discussion.

view
MEMBERS ONLY locked

Thinking Outside the Box – Referral to Interventional Pain for Cancer Pain Management

Last Updated: August 7, 2019

Presented by M. Hamza Habib, MD, FACP, FAAHPM and Stephen Ryan, RN, August 2019. While working as a palliative care MD, NP, RN, or social worker, have you ever wondered: When is it best to refer to interventional pain service for cancer pain? What individual indications or prerequisites are needed? What outcomes are expected after a referral? How long are these interventions expected to work? Is it covered by insurance, and are there any prior authorizations needed?  This session will address these questions, with special focus on interdisciplinary palliative care teams working in hospital, clinic, and field settings.

MEMBERS ONLY locked

They Say They Need More Opioids: Pain, Diversion, or Abuse in the Hospice Setting?

Last Updated: July 17, 2019

Presented by Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE and Tammie E. Quest, MD, July 2019. We are often faced with the difficult situation of trying to figure out why a home hospice patient continues to request opioid escalation. Is it increasing physical pain, or could it be opioid abuse, misuse, or diversion? Should we differentiate between these possibilities? This session will explore how to differentiate between these potential scenarios, review the best practices to address these concerns, and discuss the ethical, legal, and pragmatic implications of potential substance misuse and diversion in home hospice care.

MEMBERS ONLY locked

Searching for a Compass: A Role for Spiritual Constructs for the IDT Workflow When the Course Isn’t Clear

Last Updated: June 25, 2019

Presented by Rabbi Edith Meyerson, DMin, BCC and Rachel May Adams, MD, June 2019. Palliative care teams are frequently called upon when primary teams are stuck and in need of guidance. Many consults involve multiple layers of uncertainty caused by medical complexity, unknown prognoses, confusing emotions, conflicting goals, and more. For clinicians, patients, and families, uncertainty can be paralyzing, and attempts to move forward can be hindered for emotional and logistical reasons. So, what happens when we try to help stuck people, and then become stuck ourselves? Having a sense of groundedness, even in the midst of the uncertainty, can help palliative care teams find a way through the log jam.

MEMBERS ONLY locked

Collaborating to Facilitate Communication & Symptom Management in Patients with Acute Surgical Illness

Last Updated: May 29, 2019

Presented By Ana Berlin, MD, MPH, FACS, May 2019. This Master Clinician will highlight a case in which seriously ill patients developed acute life-altering surgical problems. The case will illustrate how effective collaboration between specialties can assist in developing balanced, patient-centered treatment plans that advance patient goals through the carefully considered deployment of surgical options and approaches.

MEMBERS ONLY locked

All of Your Patients Are Delirious: How to Recognize It and What to Do About It

Last Updated: April 26, 2019

Presented by Danielle Noreika, MD, FAAHPM, FACP and Laura Shanks, PhDc, MSN, MHA, RN, ACNS-BC, NE-BC , April 2019. Although agitated delirium is more apparent, hypoactive delirium is frequently missed and early recognition can change symptom and quality of life outcomes for patients. This presentation describes screening measures, how delirium affects symptom management, and an interdisciplinary team approach to care, including non-pharmacologic measures and medications.

MEMBERS ONLY locked

More than a Tube: Managing Swallowing Problems in Patients Receiving Palliative Care

Last Updated: March 29, 2019

Presented by Marta Kazandjian, MA CCC SLP BCS-S and Eric Widera, MD, March 2019. Presenters will describe a case example of an 87-year old woman with dementia admitted three times in the last year for aspiration pneumonia. Speakers will discuss the roles of interventions for swallowing problems.

MEMBERS ONLY locked

Navigating Complications:Utilizing Patient-Centered Quality Metrics to Identify Palliative Care Patients

Last Updated: March 4, 2019

Presented by Daniel R Hoefer M, January 2019. Presenter discusses traditional metrics and the concept of new patients centered quality metrics. Case studies will be presented to show how we may look at patients differently from a palliative perspective, engaging in their care proactively.

MEMBERS ONLY locked

"Who me? Couldnt be?" What to Do When You are Asked to Care for Kids

Last Updated: March 4, 2019

Presented by Jody Chrastek, RN, DNP, CHPN, FPCN, Diane Knust, MSW, LISW and Rebecca Kirch, JD, February 2019. An overview of key similarities and differences in caring for pediatric patients will be presented. Speakers will highlight practical resources, training and other information available to help clinicians feel comfortable and confident in stretching palliative care’s reach to support children who would benefit.

IDT strategies to support patients, families, and clinical teams through complex cases.

MEMBERS ONLY locked

Living on the Edge: Responding to Requests for "Therapies of Last Resort"

Last Updated: March 4, 2019

Presented by Gregg VandeKieft, MD, MA, and Denise Hess, MDiv, December 2018. Presenters will demonstrate compassionate, patient-centered responses to patients who request medical aid in dying and address clinician's potential moral distress raised in such cases.

MEMBERS ONLY locked

Becoming the Solution: Avoiding Palliative Care Pitfalls

Last Updated: March 4, 2019

Presented by Sandra Gomez, MD and Dominic F. Glorioso, DO, FACOI, FAAHPM, November 2018 . Presenters share how palliative care clinicians can step carefully through complex family dynamics, challenges working with other specialties to determine appropriate care versus medically ineffective treatments and devise ways to resolve them and not become part of the problem.

MEMBERS ONLY locked

Hoping for a Cure: Providing High-Quality Medical and Psychosocial Care for Seriously Ill Patients

Last Updated: March 4, 2019

Presented by Eric Widera, MD and Anne Kelly, LCSW, October 2018. The interdisciplinary care team describes challenges with medication adherence, worsening symptoms, complex family/social dynamics and spiritual care considerations for complex palliative care patients.

MEMBERS ONLY locked

Peeling Layers of Psychosocial Complexity Toward End-of-Life

Last Updated: March 4, 2019

Presented by Anne Kinderman, MD, Naomi Thoas and Jennifer McGaugh, September 2018. Presenters review the roles that interdisciplinary team members play in building trust, addressing vulnerable patient populations and framing expectations of providers involved in the care plan.

MEMBERS ONLY locked

The Use of Medical Marijuana In the Age of Increased Opioid Monitoring and Regulation

Last Updated: March 4, 2019

Presented by Stacie T. Pinderhughes, MD, Chikal Patel, MD, Julie Lehn, Pharm D and Amy Swichtenberg, NP, August 2018. Discussion focused on the medical complexity of medical marijuana use in the age of increased opioid monitoring and regulation, treating patients with a history of psychiatric challenges on multiple medications, and coordinating with multiple providers in the community to manage complex patients.

MEMBERS ONLY locked

Pain and Total Suffering: Difficult to Manage Symptoms and Suffering at End of Life in Children

Last Updated: March 4, 2019

Presented by Justin N. Baker, MD and Holly L. Spraker-Perlman, MD, MS, July 2018. Presenters discuss complex pediatric patients from St. Jude Children’s Research Hospital with an emphasis placed on taking an interdisciplinary approach toward the “total pain” and “total suffering” of patients and their families.

MEMBERS ONLY locked

Leveraging Lean Management to Optimize Patient Access and Performance

Last Updated: March 4, 2019

Presented by: Jody K. Reyes, MSBA, BSN, OCN, Jenny Mellot, RN, BSN, CRRN, and Christi Sheffield from University of Virginia Cancer Center, June 2018. Presenters describe how leaders can engage the interdisciplinary team to redesign the care delivery model by utilizing data and LEAN principles to find creative solutions aimed to increase appointment access and optimize clinic workflow.

MEMBERS ONLY locked

Decision-Making: It Takes A Health Care Village

Last Updated: March 4, 2019

Presented by: Corey L. Kennard, MACM and Arianne Lee, FNP-C, May 2018. Presenters discuss how all members of the interdisciplinary team can work together with the patient to choose a surrogate decision-maker.

MEMBERS ONLY locked

The Intricacies of Caring for a Patient with Heart Failure

Last Updated: February 3, 2019

Presented by: Tammie Quest, MD and Rebecca Chester, LCSW on April 24, 2018. Presenters focus on the benefits of working within an interdisciplinary team to help patients who find it difficult to talk about their prognosis.

MEMBERS ONLY locked

“This Pain is Mind-Numbing”: Use of Intravenous Lidocaine in Refractory Pain

Last Updated: February 3, 2019

Presented by: Charles F. von Gunten, MD,PhD and Jessica Geiger-Hayes PharmD, BCPS, CPE on April 3, 2018. Presenters describe a case of a cancer patient with intolerable pain, not responsive to traditional medications but once a lidocaine challenge dose followed by a continuous infusion made the patients radiation treatments tolerable.

MEMBERS ONLY locked

Living on a Prayer: Responding to Families who are Waiting for a Miracle

Last Updated: March 4, 2019

Presented by: Rev. Erica Richmond, M.Div, MA and Ross Howard Albert, MD, FAAFP, March 2018. Presenters share the various ways spiritual care can help all members of the interdisciplinary team navigate sensitive conversations with patients living with a serious illness.

MEMBERS ONLY locked

The Perfect Storm…Palliative Care in the Context of Pain, Addiction and Behavioral Health

Last Updated: March 4, 2019

Presented by Shelly Virva, LCSW; Lauran Hardin MSN, RN-BC, CNL; Scott Haga PA-C, January 2018. Presenters share the ways a palliative care team can intersect in positive ways in caring for complex patients with a history of substance use disorders co-occurring with mental health issues.

IDT strategies to support patients, families, and clinical teams through complex cases.

MEMBERS ONLY locked

What Puts the "Special" in Special K? The Role of Ketamine in Difficult Pain Syndromes

Last Updated: March 4, 2019

Presented by Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE and Ana A. Sanchez, MD, HMDC, October 2017. Presenters describe how the appropriate use of ketamine can be successful for patients whose pain is NOT responsive to traditional analgesics and can allow the team to meet the patient and families goals of care.

MEMBERS ONLY locked

Keeping your Team Healthy in Times of Growth or Stress

Last Updated: March 4, 2019

Presented by John Morris, MD, FAAHPM, October 2017. Presenters share tips on addressing high turnover, seemingly unmanageable consult volumes, tensions among team members, role confusion and less than effective interdisciplinary team (IDT) performance.

MEMBERS ONLY locked

I’m a Golden Glove - Supporting the Fighter Narrative in Patients with Heart Failure

Last Updated: March 4, 2019

Presented by Arden O’Donnell, MPH, MSW, LICSW and James A. Tulsky, MD, December 2017. Complex case highlights best practices in the use of the interdisciplinary team and the role of a palliative care consult service in supporting a skilled cardiology team that patients trust.

Related Toolkits See all 27 toolkits