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.
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.
Defining community-based palliative care: which patients need it, how it is delivered, and how it differs from inpatient palliative care.
Evaluating patient need, service requirements, care settings, and stakeholder priorities for the community-based palliative care program.
Translating needs assessment into service design for the community-based palliative care program.
Develop systems-thinking skills to assess situations, engage key stakeholders, and strategically prioritize resources for effective leadership.
Gain strategies to expand palliative care across settings and populations through thoughtful planning, partnerships, and collaboration.
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.
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.
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 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.
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.
Who to talk with, what to ask, and how to prepare for meetings with potential palliative care program collaborators.
This session overview offers strategies for palliative care programs to strengthen connections with communities by identifying and mobilizing resources, engaging stakeholders, and tracking impact.
Tools to help health professionals improve health equity for all people living with serious illness.
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 a budget and a business plan for the community-based program. Includes business planning tools.
Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.
Staffing models and benchmarks used by home-based programs.
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.
Compliance issues and considerations for programs working with financial partners.
Tools for all aspects of palliative care telehealth delivery, from selecting the technology platform, to ensuring meaningful encounters, to billing appropriately.
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.
Customizable workbook for community-based programs to create cost projections and key financial stats.
Qualitative explanation of budgeting and finding opportunities for cost-efficiency.
Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.
Resources for palliative care programs working with payers and other financial collaborators, including contracting resources.
Payment, billing, and fundraising tools for inpatient and community-based palliative care programs.
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.
Hire and onboard your staff, manage program operations, and ensure a healthy high-functioning team using this toolkit.
Post a position or browse for palliative care jobs. CAPC membership not required for participation.
Shared by Interim HealthCare/CarePoint.
Shared by ProHEALTH Care Support.
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.
A summary of the practical tips and strategies related to recruitment and retention from CAPC's workshop session.
Learn how to use the TeamSTEPPS SBAR Communication Tool to structure clear, concise information exchanges that improve teamwork, safety, and patient outcomes.
This learning pathway, Palliative Care Registered Nurse Onboarding Curriculum, contains recommended clinical training for new registered nurses on the specialty palliative care team.
This learning pathway, Palliative Care Provider Onboarding Curriculum, contains recommended clinical training for new providers on the specialty palliative care team.
This learning pathway, Palliative Care Social Worker Onboarding Curriculum, contains recommended clinical training for new social workers on the specialty palliative care team.
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.
Use this toolkit to select program measures that demonstrate value and support quality care delivery. Overcome common measurement obstacles and synthesize program data.
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.
Toolkit for finding the right patients at the right time to address gaps in care.
Home-based palliative care consult screening tool that lists clinical and psychosocial criteria to help determine when a palliative medicine consult should be requested.
Establishing referral partnerships to address gaps in care for palliative care patients.
Guidance on dosing interventions allocating visit frequency based on patient risk.
Tools for refining your palliative care program’s marketing strategy, and your messaging.
Shared by ProHEALTH Care Support.
Use this scale to assess the patient's functional abilities including ambulation, activity level, self-care ability, intake, and consciousness.
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.
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.
Medical Economics article provides tips on how to improve communication between primary and specialty care.
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.
This communication script provides techniques for clinicians to foster meaningful conversations about hospice.
Shared by ProHEALTH Care Support.
Sample opioid treatment agreement.
The HSSAT checklist helps identify home hazards that could cause falls. Check each room, mark problems, and then fix them.
Use this checklist to alert you to potential hazards in an older person's home.
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Center to Advance Palliative Care
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Leaderly Consultants
Chief Executive Officer, Center to Advance Palliative Care
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Center to Advance Palliative Care
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