Patients are living longer with serious illness, and their care is increasingly moving out of the hospital and into the home.

This toolkit is organized into six sections, each building on the previous one. Courses listed first in each section provide a framework for how to use the tools and resources that follow. Additional toolkits may be linked within each section, and the resources they contain offer valuable support for designing your home-based palliative care program.

What’s in the Toolkit

These courses and resources are designed to help build a foundation for home-based palliative care, then apply that knowledge using the worksheets and tools to assess needs, map resources, and engage collaborators. Involving patients, families, leadership, referrers, and financial partners throughout this process will ensure the program design reflects their priorities.

Introduction to Palliative Care in the Community

Defining community-based palliative care: which patients need it, how it is delivered, and how it differs from inpatient palliative care.

Needs Assessment: Ensuring Successful Community-Based Palliative Care

Evaluating patient need, service requirements, care settings, and stakeholder priorities for the community-based palliative care program.

Program Design for Palliative Care Delivered in the Home

Translating needs assessment into service design for the community-based palliative care program.

Leading with Purpose: Developing a Strategic Mindset and Assessing Program Needs
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Develop systems-thinking skills to assess situations, engage key stakeholders, and strategically prioritize resources for effective leadership.

Building Strategic Relationships: Partnering to Grow Impact and Access
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Gain strategies to expand palliative care across settings and populations through thoughtful planning, partnerships, and collaboration.

Planning for Community-Based Care: Getting Started

In this Virtual Office Hour, ask questions of expert faculty about launching a new community-based program, designing your service package and staffing, and navigating the challenges of a new program.

National Consensus Project for Quality Palliative Care, 4th edition

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.

Recommendations for Palliative Care Program Standards

Basic standards for specialty palliative care programs, for use by health care organizations, payers and policymakers. Note: these recommendations were published in May 2025. CAPC is currently in process of collecting feedback from the palliative care field, and will iterate these standards accordingly.

The Case for Community-Based Palliative Care

The majority of people with serious illness are neither dying nor hospitalized. So, palliative care needs to be available in all settings outside hospitals—in medical offices and clinics, in post-acute and long-term care facilities, and in patient homes. This publication includes key data on the value of community palliative care, program profiles, and a case example to use with leadership.

Community-Based Palliative Care Needs Assessment and Decision-Making Tool
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Step-by-step tool to evaluate patient need, stakeholder priorities, organizational readiness, and sites of care for a new or growing community-based palliative care service.

Engaging Collaborators
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Who to talk with, what to ask, and how to prepare for meetings with potential palliative care program collaborators.

Harnessing the Power of Community Mapping
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This session overview offers strategies for palliative care programs to strengthen connections with communities by identifying and mobilizing resources, engaging stakeholders, and tracking impact.

Health Equity

Tools to help health professionals improve health equity for all people living with serious illness.

Sample Palliative Care Program Mission Statements
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Sample Palliative Care Program Mission Statements from six program leaders.

These courses and resources will help ensure efficient and effective program design, then use resources on business planning, staffing models, and toolkits for hospice-led care, telehealth, and regulatory considerations to align services with patient, organizational, and referrer needs.

Building the Business Plan for Community-Based Palliative Care

Building a budget and a business plan for the community-based program. Includes business planning tools.

Palliative Care in the Home: A Guide to Program Design (PDF Download)
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Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.

Staffing Models Inventory for Value-Based Home-Based Palliative Care Programs
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Staffing models and benchmarks used by home-based programs.

Spotlight on Home-Based Palliative Care: Insights and Recommendations from CAPC and PCQC

This report from the Center to Advance Palliative Care (CAPC) and the Palliative Care Quality Collaborative (PCQC) examines key characteristics of home-based palliative care programs from across the U.S.—including patients served, program operations and funding, and national staffing averages. The report also shares recommendations that payers and policymakers might use to credential home-based palliative care providers.

Regulatory and Licensure Considerations for Community-Based Palliative Care
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Compliance issues and considerations for programs working with financial partners.

Telehealth

Tools for all aspects of palliative care telehealth delivery, from selecting the technology platform, to ensuring meaningful encounters, to billing appropriately.

Hospice-Led Palliative Care

Designing high-quality, sustainable palliative care as a separate business line.

Financing is a critical element of program design, shaping how services are delivered and sustained. Equally important is optimizing your EHR to ensure accurate billing, regulatory compliance, and maximum financial reimbursement.

Financial Analysis and Budgeting Tool for Community-Based Palliative Care
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Customizable workbook for community-based programs to create cost projections and key financial stats.

Understanding Costs and Prices: Companion Guide for Financial Analysis and Budgeting Tool
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Qualitative explanation of budgeting and finding opportunities for cost-efficiency.

Billing and Coding

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

Contracting to Finance Palliative Care Services

Resources for palliative care programs working with payers and other financial collaborators, including contracting resources.

Beyond Billing: Covering Costs and Generating Revenue

Payment, billing, and fundraising tools for inpatient and community-based palliative care programs.

Billing for Community-Based Palliative Care

In this Virtual Office Hour, ask questions about billing for services provided in the home, office, or long-term care setting.

Staffing and training support strong, sustainable palliative care teams. Resources cover team development, recruitment and retention, wellness, and clinical skills in symptom management, dementia, COPD, falls, advance care planning, communication, and caregiver support.

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.

Find a Career in Palliative Care

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

Collaborative Practice Agreement
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Shared by Interim HealthCare/CarePoint.

Volunteer Guidelines
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Shared by ProHEALTH Care Support.

Wellness and Workforce Recruitment and Retention Strategies

This on-demand session explores the relationship between recruitment and retention and present data that suggests that recruitment and retention strategies are not “one size fits all” among disciplines.

CAPC Workshop Materials: Recruitment and Retention Quick Tips Summary
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A summary of the practical tips and strategies related to recruitment and retention from CAPC's workshop session.

SBAR Communication Tool for Teams
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Learn how to use the TeamSTEPPS SBAR Communication Tool to structure clear, concise information exchanges that improve teamwork, safety, and patient outcomes.

Palliative Care Registered Nurse Onboarding Curriculum

This learning pathway, Palliative Care Registered Nurse Onboarding Curriculum, contains recommended clinical training for new registered nurses on the specialty palliative care team.

Palliative Care Provider (MD, PA, and NP) Onboarding Curriculum

This learning pathway, Palliative Care Provider Onboarding Curriculum, contains recommended clinical training for new providers on the specialty palliative care team.

Palliative Care Social Worker Onboarding Curriculum

This learning pathway, Palliative Care Social Worker Onboarding Curriculum, contains recommended clinical training for new social workers on the specialty palliative care team.

Age-Friendly Health Care

This Learning Pathway contains comprehensive knowledge and skills training across the 4Ms of age-friendly health care for older adults.

These resources guide operations from measurement and performance improvement to patient assessment and eligibility, then build on that foundation with partnerships and marketing to expand access and engagement.

Measurement Best Practices

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

CAPC Continuous Quality Improvement Basics
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An overview of the CQI process: choosing the right problem, setting SMART goals, analyzing root causes, testing solutions, measuring impact, and scaling results to gain leadership buy-in.

Patient Identification and Assessment

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

Home Based Palliative Care Screening Tool
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Home-based palliative care consult screening tool that lists clinical and psychosocial criteria to help determine when a palliative medicine consult should be requested.

Palliative Care Partnerships: Leveraging Collaboration to Improve Access to Community Based Palliative Care

Establishing referral partnerships to address gaps in care for palliative care patients.

Population Stratification Considerations
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Guidance on dosing interventions allocating visit frequency based on patient risk.

Tip Sheet: Marketing Home-Based Palliative Care to Potential Referrers
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Marketing and Messaging Palliative Care

Tools for refining your palliative care program’s marketing strategy, and your messaging.

Intake Home Visit Checklist
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Shared by ProHEALTH Care Support.

Palliative Performance Scale
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Use this scale to assess the patient's functional abilities including ambulation, activity level, self-care ability, intake, and consciousness.

STEADI - Older Adult Fall Prevention
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STEADI is the CDC’s initiative for older adult fall prevention, offering clinical tools, training, and patient resources to assess fall risk and implement interventions.

CAPC Fall Risk Assessment Guide
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This resource offers practical tools and communication strategies to help home-based palliative care teams prevent falls, align care with patient goals, and promote safety and independence at home.

What Happens When Doctors Don’t Talk to Each Other

Medical Economics article provides tips on how to improve communication between primary and specialty care.

Reducing Palliative Care Stigma in Oncology

Summary and Clinical Action Items from the ACS/CAPC Webinar

These resources offer sample policies and procedures for consistent, high-quality home-based palliative care, covering clinical operations, symptom management, care planning, safety, patient rights, and practical tools.

Conversation Script: Talking to Patients About Hospice

This communication script provides techniques for clinicians to foster meaningful conversations about hospice.

Mileage Reimbursement Tool
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Shared by ProHEALTH Care Support.

Opioid Treatment Agreement
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Sample opioid treatment agreement.

Home Safety Self Assessment Tool
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The HSSAT checklist helps identify home hazards that could cause falls. Check each room, mark problems, and then fix them.

Home Safety Checklist
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Use this checklist to alert you to potential hazards in an older person's home.

See all 46 Toolkits

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