Clinical Tools for Delivering High-Quality Care

This collection of tools is a one-stop shop for interdisciplinary teams caring for patients living with a serious illness. The tools and resources on this page can be used to screen for, assess, document, and manage the palliative needs of patients and their caregivers. Teams will also find guidance on how to support team health, promote role clarity, and improve practice efficiency.

What’s in the Toolkit

Validated tools to screen for and assess physical symptoms, anxiety, depression, spiritual distress, cognitive impairment, caregiver burden, and other factors that impact quality of life for patients and caregivers.

Revised Edmonton Symptom Assessment System (ESAS-r)

Last Updated: January 29, 2019

Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Edmonton Zone Regional Palliative Care Program, 2010.

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Condensed Memorial Symptom Assessment Scale (CMSAS)

Last Updated: February 3, 2019

Measures the frequency, severity, and distress associated with 32 symptoms.

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NCCN Distress Thermometer

Last Updated: January 29, 2019

Assessment tool for symptom burden and impact on quality of life. National Comprehensive Cancer Network (NCCN), 2016.

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Palliative Performance Scale

Last Updated: February 3, 2019

Assesses the patient's functional abilities including ambulation, activity level, self-care ability, intake and consciousness.

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ECOG Performance Status

Last Updated: February 3, 2019

Assess disease progression, impact on activities of daily living, and appropriate treatment and prognosis.

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Pain Assessment Questions

Last Updated: January 29, 2019

Recommended assessment questions to typify pain and inform pain management for patients with serious illness. Center to Advance Palliative Care, 2015.

Pain Assessment and Documentation Tool (PADT)

Last Updated: February 3, 2019

Validated instrument to assess pain intensity and impact on function over time.

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Wong-Baker FACES Pain Rating Scale

Last Updated: February 1, 2019

Illustrated pain scale for patients with cognitive impairment and children.

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Pain Assessment in Advanced Dementia (PAINAD)

Last Updated: February 3, 2019

Tool to assess pain in cognitively impaired patients.

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PHQ-4 Validated Screening Tool for Anxiety and Depression

Last Updated: February 3, 2019

Brief (4-question) screening tool for anxiety and depression.

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PHQ-9: Validated Screening Tool for Depression

Last Updated: February 25, 2019

Used to screen, diagnose and measure the severity of depression.

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GAD-7 Anxiety Scale

Last Updated: February 3, 2019

Measure for assessing generalized anxiety disorder.

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Spiritual Screening Tool

Last Updated: November 22, 2019

Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.

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AD8 Dementia Screening

Last Updated: February 3, 2019

Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.

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FAST Scale

Last Updated: February 26, 2019

For staging and prognosis after a dementia diagnosis.

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Zarit Burden Interview (ZBI-12)

Last Updated: October 23, 2019

Self-reported caregiver assessment.

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CMS Accountable Health Communities Screening for Health-Related Social Needs

Last Updated: February 3, 2019

Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model.

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Practical references for clinicians to support pain and symptom management and to navigate difficult conversations with patients and families.

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Equianalgesic Conversion Table

Last Updated: June 20, 2019

Depicts the relative potencies of commonly prescribed opioids compared to oral morphine.

Opioid Risk Tool (ORT)

Last Updated: February 3, 2019

Validated 5-question assessment tool designed to predict which patients are at risk for opioid substance use disorder.

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Starting Doses in the Opioid-naïve Patient

Last Updated: June 20, 2019

Safe starting doses for the opioid-naïve patient.

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Analgesics Fact Sheet

Last Updated: January 29, 2019

When to use - and when to avoid - 6 classes of analgesics including acetaminophen, NSAIDs, opioids, antiepileptics, antidepressants, and corticosteroids. Center to Advance Palliative Care, updated 2018.

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Opioid Treatment Agreement

Last Updated: February 3, 2019

Shared by Optio Health Services.

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics

Last Updated: October 23, 2019

U.S. Department of Health and Human Services. October 2019.

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Constipation Protocol

Last Updated: January 29, 2019

Sample protocol for managing constipation. Organizations can create similar protocols in collaboration with referring clinicians and pharmacists. Lee Health, 2013.

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Communication Phrases in Palliative Care

Last Updated: January 29, 2019

Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.

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Advance Care Planning Conversations: Key Takeaways

Last Updated: January 29, 2019

Stepwise approach to discussing advance care planning with patients or surrogates. Center to Advance Palliative Care and VitalTalk, 2015.

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Conducting a Family Meeting: Key Takeaways

Last Updated: January 29, 2019

Stepwise approach that any clinician can use to improve family meetings. Center to Advance Palliative Care and VitalTalk, 2015.

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Delivering Serious News: Key Takeaways

Last Updated: January 29, 2019

Stepwise approach for conversations with patients about serious news. Center to Advance Palliative Care and VitalTalk, 2015.

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Discussing Prognosis: Key Takeaways

Last Updated: January 29, 2019

Stepwise approach for discussing prognosis with patients and families. Center to Advance Palliative Care and VitalTalk, 2015.

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Clarifying Goals of Care: Key Takeaways

Last Updated: January 28, 2020

Stepwise approach to conversations with patients about their goals of care. Center to Advance Palliative Care and VitalTalk, 2019.

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Discussing Your Patient's Dementia Diagnosis Key Takeaways

Last Updated: January 29, 2019

Stepwise approach for discussing a dementia diagnosis with patients and caregivers. Center to Advance Palliative Care, 2018.

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Communicating About What to Expect as Dementia Progresses: Key Takeaways

Last Updated: January 29, 2019

Key takeaways and list of available community resources for people living with dementia and their caregivers.

Dementia Care Resources for Caregivers

Last Updated: March 21, 2019

Print or email this handout of caregiver resources for education and support.

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Tips for Communicating with People Living with Dementia

Last Updated: January 29, 2019

Guidelines for clinicians and caregivers. Center to Advance Palliative Care, 2018.

Dementia Care Resources for Caregivers

Last Updated: March 21, 2019

Print or email this handout of caregiver resources for education and support.

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A Guide for Conducting an ICU Family Meeting When the Patient Is Unable to Participate

Last Updated: February 3, 2019

Communication framework for discussing goals of care with families of patients in the ICU.

Template notes for documenting patient care.

Pain Assessment and Documentation Tool (PADT)

Last Updated: January 29, 2019

Validated instrument to assess pain intensity and impact on function over time.

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Palliative Care Progress Note

Last Updated: May 10, 2019

An effective progress note based on the core domains of palliative care is one of your best marketing tools. There's no better way to effectively show referral sources what palliative care can do. Sample document shared by Carle Foundation Hospital, 2017.

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Social Work Consultation Note

Last Updated: March 26, 2019

Rounding tool, triage system, and team meeting guide to support an efficient, high-functioning team.

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Daily Team Meetings: Triage System

Last Updated: February 23, 2019

Guidelines for effective team meeting management.

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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.

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Billing Outpatient Tip Sheet

Last Updated: September 5, 2019

Quick reference to help clinicians with clinic based outpatient billing and coding. Center to Advance Palliative Care, 2019.

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Billing Home Tip Sheet

Last Updated: September 5, 2019

Quick reference to help clinicians with home based billing and coding. Center to Advance Palliative Care, 2019.

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Billing Inpatient Tip Sheet

Last Updated: October 11, 2019

Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.

Faculty

Related Toolkits See all 29 toolkits

Building and Supporting Effective Palliative Care Teams

Hire and onboard your staff, manage program operations, and ensure a healthy high-functioning team using this toolkit.

Includes 66 resources:
  • Hiring and Onboarding
  • Sample Job Descriptions
  • Day-to-Day Program Operations
  • Interdisciplinary Team Roles
  • Team Health and Resilience
  • Patient Identification and Trigger Tools
  • Working With Referrers
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Patient Identification and Assessment

Toolkit for finding the right patients at the right time to address gaps in care.

Includes 49 resources:
  • For Inpatient Providers
  • For Community-Based Providers
  • For Systems, Plans, and Accountable Care Organizations
  • Clinical Assessment Tools
  • Information for Patients about Palliative Care
Learn More

Training All Clinicians in Essential Communication and Symptom Management Skills

Tools to design and implement a training initiative for care teams from all specialties, to improve quality of life for patients and families living with serious illness.

Includes 21 resources:
  • The Case for Communication and Symptom Management Training
  • CAPC Curriculum
  • Training by Specialty or Discipline
  • Implementing a Training Program
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