Designing a Long-Term Care Palliative Care Program
Nursing homes, assisted living residences, and continuing-care retirement communities provide palliative care services to residents via several models:
- In-house palliative care teams
- Contracting with external community-based palliative care programs to provide consults to residents
- Training clinical staff across the organization in core palliative care skills
Use this toolkit to evaluate models and design and operate your long-term care palliative care program.
What’s in the Toolkit
Program Design: Comprehensive Guidance
A compilation of summary guidance for improving quality of life and access to palliative care specialists in long-term care settings.
A foundational document that describes the role of, and a range of models for, palliative care in nursing homes. Center to Advance Palliative Care, 2008.
Principles and best practices for palliative care in nursing homes. Avila Institute of Gerontology, 2017.
Explanation of what to do for residents of long-term care facilities. CIVHC, 2012
Care practices, tools, and case studies designed for front line staff at residentail care facilities. Shared by CaringKind, 2016.
Design and outcomes of two nursing home programs aimed at increasing access to palliative care and decreasing re-hospitalizations. Journal of Social Work in End-of-Life Care and Palliative Care, 2015.
Tools for developing palliative care programs in skilled nursing facilities. Created by The Nursing Home Palliative Care Collaborative of Rhode Island, 2014.
Summary of key strategies for special needs plans, with a specific look at institutional special needs plans. CAPC for the SNP Alliance 2017
Summary best practices and tips for PACE organizations to improve care for participants through palliative care principles, practices, and specialists.
In this Virtual Office Hour, ask questions about strategic planning, program design, and program operations for palliative care in long-term care settings.
Identifying Patients and Residents in Need of Palliative Care
Use these resources to establish criteria for finding patients in need of palliative care services, and assessing their needs.
A document with guidance and sample orders to assist nursing homes in identifying patients and residents with limited prognoses. INTERACT II.
Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.
Used to identify patients at high risk for readmission or death.
Online tool that predicts risk of death within one year of hospitalization, specific to patients aged 70+.
Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.
Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.
Summary of best practices in identifying those in need of palliative care, holding meaningful conversations, and collaborating with hospice when needed.
Clinical Training for All Staff
Training in core skills to improve quality of life - including communication, symptom management, dementia care, and supporting family caregivers - for all professionals working in long-term care settings.
Summary list of recommended CAPC clinical CE courses by role. Topics include communication skills, symptom management, dementia care, and more. Center to Advance Palliative Care, 2019.
Summary list of recommended CAPC clinical CE courses by role on a PACE team. Includes "on-boarding" and annual refresher recommendations.
Recommended CAPC courses for long-term care case managers. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for CNAs in long-term care organizations. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for long-term care intake staff. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for providers working in long-term care. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for OT, PT, and SLP professionals working in long-term care. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for RNs working in long-term care. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for long-term care social workers. Center to Advance Palliative Care, 2019.
Recommended CAPC courses for spiritual care providers working in long-term care. Center to Advance Palliative Care, 2019.
How to engage staff in a clinical training initiative using CAPC's online courses.
Course catalog for CAPC's clinical training curriculum. Onboard new palliative care team members using standardized training, or train non-palliative care specialists in core skills. All courses provide continuing education credits for all disciplines and are free for CAPC members.
Specialty Palliative Care Programs in Long-term Care
Models and practices to optimize the services and supports for specialty palliative care teams.
Study describing consultation programs and their impact on hospital transfers, across 4 states. Journal of Pain and Symptom Management 2016.
A background on payment and quality of care in nursing homes, and one team's success in reducing avoidable hospital transfers.
Searchable directory of specialty palliative care providers, filtered by care setting.
Eric Widera, MD, reviews a study associating nursing home palliative care with decreased hospitalizations and burdensome transfers. GeriPal, 2016.
Billing practices that reflect the complexity of palliative care services delivered in skilled nursing facilities and nursing homes. Center to Advance Palliative Care, 2020.
Designing high-quality, sustainable palliative care as a separate business line.
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.
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.
This is an example of a form utilized by providers to request a palliative care consult. Palliative Care Associates, a program of Hospice and Palliative Care of Greensboro, August 2018.
Shared by Interim HealthCare/CarePoint.
A document describing the impact of palliative care conversations with long-term care residents during COVID-19.
Case Studies and Evidence
A spectrum of palliative care models exist to meet patient needs in long-term care settings, with a growing evidence base of improved quality and value.
Community-based palliative care program serving patients across multiple SNFs.
Comprehensive health care system offering skilled nursing and special rehabilitation program with a community component providing home health care, day care services, home assistance, geriatric case management, and a research division.
Summary of two approaches to integrating palliative care into post-acute care. CAPC 2017
Findings from the Centers for Medicare and Medicaid Service's Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Health Affairs, 2017.
Pivotal articles pertaining to palliative care delivery in long-term care organizations.
Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
Jeanne Sheils Twohig, MPA
Center to Advance Palliative Care
Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Center to Advance Palliative Care
Allison Silvers, MBA
Chief Health Care Transformation Officer