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. Practices participating in the Serious Illness Population (SIP) option under CMMI’s Primary Care First initiative can especially benefit from these tools.
What’s in the Toolkit
Functional Assessment
A collection of tools that clinicians can use to assess and track functional status of patients with serious illness.
Assesses the patient's functional abilities including ambulation, activity level, self-care ability, intake and consciousness.
Assess disease progression, impact on activities of daily living, and appropriate treatment and prognosis.
Symptom Assessment
Validated symptom assessment tools clinicians can use to assess and track symptom burden in serious illness.
Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.
Measures the frequency, severity, and distress associated with 32 symptoms.
Recommended assessment questions to typify pain and inform pain management for patients with serious illness.
Validated instrument to assess pain intensity and impact on function over time.
Adapted from the Opioid Risk Tool questionnaire developed by Lynn R. Webster, MD to assess risk of opioid use disorder. This adapted version uses currently recommended terminology, for example ‘opioid use disorder’ and ‘substance use disorder’.
Illustrated pain scale for patients with cognitive impairment and children.
Tool to assess pain in cognitively impaired patients.
Psychological and Social Assessment
A collection of tools to assist clinicians in the assessment of the psychological and social impact of serious illness on their patients, and their caregivers.
Assessment tool for symptom burden and impact on quality of life. National Comprehensive Cancer Network (NCCN), 2016.
Brief (4-question) screening tool for anxiety and depression.
Used to screen, diagnose and measure the severity of depression.
Measure for assessing generalized anxiety disorder.
Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.
Self-reported caregiver assessment.
Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model, and recommended for Medicare and Medicaid beneficiaries.
Dementia Care
A collection of tools to aid clinicians in the screening, assessment, and staging of patients with dementia.
Tool to assess pain in cognitively impaired patients.
Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.
For staging and prognosis after a dementia diagnosis.
Print or email this handout of caregiver resources for education and support.
Guidelines for clinicians and caregivers.
Opioid Prescribing Tools and Resources
A collection of tools to assist clinicians with the safe and effective use of opioids to relieve suffering for patients with serious illness.
Recommended assessment questions to typify pain and inform pain management for patients with serious illness.
Validated instrument to assess pain intensity and impact on function over time.
Adapted from the Opioid Risk Tool questionnaire developed by Lynn R. Webster, MD to assess risk of opioid use disorder. This adapted version uses currently recommended terminology, for example ‘opioid use disorder’ and ‘substance use disorder’.
Illustrated pain scale for patients with cognitive impairment and children.
Depicts the relative potencies of commonly prescribed opioids compared to oral morphine.
Opioid pocket reference for providers including safe starting doses, equianalgesic chart, and standard dosing strengths.
Safe starting doses for the opioid-naïve patient.
When to use - and when to avoid - 6 classes of analgesics including acetaminophen, NSAIDs, opioids, antiepileptics, antidepressants, and corticosteroids.
Shared by Optio Health Services.
U.S. Department of Health and Human Services. October 2019.
Sample protocol for managing constipation. Organizations can create similar protocols in collaboration with referring clinicians and pharmacists. Lee Health, 2013.
Communication Tools and Resources
A collection of tools and technical assistance to help clinicians improve communication with patients and families living with serious illness.
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.
Stepwise approach to discussing advance care planning with patients or surrogates. Center to Advance Palliative Care and VitalTalk.
Stepwise approach that any clinician can use to improve family meetings. Center to Advance Palliative Care and VitalTalk.
Stepwise approach for conversations with patients about serious news. Center to Advance Palliative Care and VitalTalk.
Stepwise approach for discussing prognosis with patients and families. Center to Advance Palliative Care and VitalTalk.
Stepwise approach to conversations with patients about their goals of care. Center to Advance Palliative Care and VitalTalk.
Stepwise approach for discussing a dementia diagnosis with patients and caregivers.
Key takeaways and list of available community resources for people living with dementia and their caregivers.
Communication framework for discussing goals of care with families of patients in the ICU.
Documentation
Template notes for documenting patient care.
Validated instrument to assess pain intensity and impact on function over time.
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.
Shared by Hospital of University of Pennsylvania.
Shared by Central Baptist Hospital.
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
Shared by Interim HealthCare/CarePoint.
Form utilized by our providers during the first visit to inform and document patient and family HIPPA and billing responsibilities. Palliative Care Associates, a program of Hospice and Palliative Care of Greensboro, August 2018.
Documentation of patient and clinician goals and expectations for safe and effective opioid treatment.
Team Tools
Rounding tool, triage system, and team meeting guide to support an efficient, high-functioning team.
Guidelines for effective team meeting management.
Best practices in efficient, effective IDT meetings.
Quick reference to help clinicians with clinic based outpatient billing and coding.
Quick reference to help clinicians with home based billing and coding.
Quick reference to help clinicians with inpatient billing and coding.
Sample geriatrics and palliative team survey to assess patient satisfaction.
Sample survey to assess palliative care patient satisfaction.
Sample palliative care patient experience survey.
