Patients are living longer with serious illness, and their care is moving out of the hospital and into community care settings. For the sickest patients, this means care delivered in the home. Practices working "upstream" from hospice organizations can especially benefit from these tools.
This toolkit was developed by the CAPC Home-Based Palliative Care Workgroup. We thank the eleven members of the workgroup for contributing their expertise and program materials.
Workgroup Chair:
Donna Stevens, MHA, Program Director, OACIS/Palliative Medicine, Lehigh Valley Health Network, Allentown, PA, representing the OACIS/Palliative Care Home-Based Consult Service.
Download a full listing of participants and programs in the CAPC Home-Based Palliative Care Workgroup. For program profiles, see Palliative Care in the Home: A Guide to Program Design.
Engage partners—patients and families, organizational leadership, referrers, and financial partners—to guide program design that is aligned with their priorities.
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.
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.
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.
Define strengths and opportunities as you seek financial and referral partners.
Exploring the expansive role of the Community Health Worker (CHW), a long-standing member of the health care team, who helps to bring more culturally-responsive care.
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.
Home-based palliative care models are designed to match patient need, organizational priorities, and referrer relationships.
Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.
Translating needs assessment into service design for the community-based palliative care program.
Customizable workbook for community-based programs to create cost projections and key financial stats.
Qualitative explanation of budgeting and finding opportunities for cost-efficiency.
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.
Palliative Care Leadership Centers (PCLC) provide palliative care teams the skills and organizational abilities needed to develop and deliver the highest-quality, sustainable programs.
Shared by ProHEALTH Care Support.
Shared by Interim HealthCare/CarePoint, 2017
Key components of telehealth service delivery, especially in a home-based palliative care program.
Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.
Building a budget and a business plan for the community-based program. Includes business planning tools.
Many hospices offer palliative care as a separate business line. Use these tools to navigate palliative care program start-up and operations.
Designing high-quality, sustainable palliative care as a separate business line.
In this Virtual Office Hour, ask questions about operating a community-based palliative care program under your hospice organization, including referrals across service lines, financing strategies, and how to communicate your service lines to patients.
Considerations for the hospice before starting a non-hospice palliative care service line. Webinar presentation.
Differentiating hospice and palliative care services and eligibility. Webinar presentation.
Assists hospices operating community palliative care programs to understand five key steps to take before launching their program. Center to Advance Palliative Care, 2019.
Checklist for assessing organizational capacity to launch a non-hospice palliative care service. Center to Advance Palliative Care, 2019.
Guidance for clarifying boundaries between hospice and palliative care services, and building internal cohesion. Center to Advance Palliative Care, 2019.
Program design considerations including patients, services, and staff. Center to Advance Palliative Care, 2019.
It is essential to collect data that matter to program stakeholders—including patients—and that facilitate continuous quality improvement. Use these tools to identify measures, collect data, and use your data to demonstrate program value.
Use this toolkit to select program measures that demonstrate value and support quality care delivery. Overcome common measurement obstacles and synthesize program data.
Excerpted from the Guide to Home-Based Program Design. Center to Advance Palliative Care, 2017.
Recommendations for measures and approaches to evaluating palliative care services that enable growth and improvement.
Identify appropriate patients for your program, and assess their palliative care needs.
Toolkit for finding the right patients at the right time to address gaps in care.
Shared by Sutter Health-Advanced Illness Management (AIM).
For referrers. Shared by OACIS/ Lehigh Valley Health Network.
For referrers. Shared by Optio Health Services.
Shared by ProHEALTH Care Support.
Establishing referral partnerships to address gaps in care for palliative care patients.
Guidance on dosing interventions allocating visit frequency based on patient risk.
Shared by Interim HealthCare/CarePoint.
Protocols used by home-based programs to standardize team practice and optimize patient outcomes.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by ProHEATH Care Support.
Sample materials to explain program benefits and services to patients, families, and referrers.
Shared by ProHEATH Care Support.
Shared by ProHEATH Care Support.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
On the benefits of partnering with the palliative care program. Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by OACIS/Lehigh Valley Health Network.
Shared by Sutter Health-Advanced Illness Management (AIM).
Sample brochure shared by Hospice of Buffalo.
Shared by ProHEALTH Care Support.
Shared by Optio Health Services.
Tools to support team development and sample job descriptions for a home-based program.
Staffing models and benchmarks used by home-based programs.
Hire and onboard your staff, manage program operations, and ensure a healthy high-functioning team using this toolkit.
Shared by ProHEALTH Care Support.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Interim HealthCare/CarePoint.
Shared by Interim HealthCare/CarePoint.
Shared by Sutter Health-Advanced Illness Management (AIM).
Sample job description for role to assist with coordination between "usual care" and the palliative care team, especially during transitions. Shared by Interim HealthCare/CarePoint.
Shared by Meridian Health.
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by Sutter Health-Advanced Illness Management (AIM).
Presentation on role clarity in the home-based palliative care IDT.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Sutter Health-Advanced Illness Management (AIM).
Shared by OACIS/Lehigh Valley Health Network.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by Meridian Health.
Shared by ProHEALTH Care Support.
Home-based palliative care program efficiency depends upon balancing the need for patient contact with drive times. Many programs use telehealth to maintain contact with patients when home visits are not required, in order to enable program growth and scale.
Key components of telehealth service delivery, especially in a home-based palliative care program.
Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.
Provides a review of the current evidence for telepalliative care and potential applications and practical tips for using the technology.
Working in the home can be unpredictable. Use these tools to ensure safe, respectful interactions in patients’ homes.
Shared by ProHEALTH Care Support.
Excerpted from the Guide to Palliative Care in the Home.
Shared by ProHEALTH Care Support.
Sample opioid treatment agreement.
Institute for Healthcare Improvement, August 2017.
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
Consultant
Center to Advance Palliative Care
Partner
Leaderly Consultants
Chief Executive Officer, Center to Advance Palliative Care
Consultant
Center to Advance Palliative Care
