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
Screening and Assessment Tools
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)
Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Edmonton Zone Regional Palliative Care Program, 2010.
viewCondensed Memorial Symptom Assessment Scale (CMSAS)
Measures the frequency, severity, and distress associated with 32 symptoms.
viewNCCN Distress Thermometer
Assessment tool for symptom burden and impact on quality of life. National Comprehensive Cancer Network (NCCN), 2016.
viewPalliative Performance Scale
Assesses the patient's functional abilities including ambulation, activity level, self-care ability, intake and consciousness.
viewECOG Performance Status
Assess disease progression, impact on activities of daily living, and appropriate treatment and prognosis.
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Pain Assessment Questions
Recommended assessment questions to typify pain and inform pain management for patients with serious illness. Center to Advance Palliative Care, 2015.
members loginPain Assessment and Documentation Tool (PADT)
Validated instrument to assess pain intensity and impact on function over time.
viewWong-Baker FACES Pain Rating Scale
Illustrated pain scale for patients with cognitive impairment and children.
viewPain Assessment in Advanced Dementia (PAINAD)
Tool to assess pain in cognitively impaired patients.
viewPHQ-4 Validated Screening Tool for Anxiety and Depression
Brief (4-question) screening tool for anxiety and depression.
downloadPHQ-9: Validated Screening Tool for Depression
Used to screen, diagnose and measure the severity of depression.
downloadGAD-7 Anxiety Scale
Measure for assessing generalized anxiety disorder.
downloadSpiritual Screening Tool
Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.
downloadAD8 Dementia Screening
Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.
viewFAST Scale
For staging and prognosis after a dementia diagnosis.
viewZarit Burden Interview (ZBI-12)
Self-reported caregiver assessment.
viewCMS Accountable Health Communities Screening for Health-Related Social Needs
Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model.
downloadPatient Care Tools
Practical references for clinicians to support pain and symptom management and to navigate difficult conversations with patients and families.
Equianalgesic Conversion Table
Depicts the relative potencies of commonly prescribed opioids compared to oral morphine.
downloadOpioid Risk Tool (ORT)
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
Safe starting doses for the opioid-naïve patient.
members loginAnalgesics Fact Sheet
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
Shared by Optio Health Services.
members loginHHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics
U.S. Department of Health and Human Services. October 2019.
viewConstipation Protocol
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
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
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
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
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
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
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
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
Key takeaways and list of available community resources for people living with dementia and their caregivers.
members loginDementia Care Resources for Caregivers
Print or email this handout of caregiver resources for education and support.
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Tips for Communicating with People Living with Dementia
Guidelines for clinicians and caregivers. Center to Advance Palliative Care, 2018.
members loginDementia Care Resources for Caregivers
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
Communication framework for discussing goals of care with families of patients in the ICU.
members loginDocumentation
Template notes for documenting patient care.
Pain Assessment and Documentation Tool (PADT)
Validated instrument to assess pain intensity and impact on function over time.
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Palliative Care Progress Note
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
Shared by Central Baptist Hospital.
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Consent Agreement
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
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Informed Consent
Shared by Interim HealthCare/CarePoint.
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Palliative Care Consent Form Example
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.
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Sample Treatment Agreement/Informed Consent Form
Documentation of patient and clinician goals and expectations for safe and effective opioid treatment.
members loginTeam Tools
Rounding tool, triage system, and team meeting guide to support an efficient, high-functioning team.
Daily Team Meetings: Triage System
Guidelines for effective team meeting management.
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Quick Tips #5: Running Effective Interdisciplinary Team Patient Care Meetings
Best practices in efficient, effective IDT meetings. Center to Advance Palliative Care, 2018.
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Billing Outpatient Tip Sheet
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
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
Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.
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Related Toolkits See all 30 toolkits
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
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