Patients and families living with serious illness have a range of needs beyond disease treatment, including support for functional limitation, pain and other symptoms, and caregiver burden.

Use this toolkit to establish criteria for finding the right patients at the right time and assessing their physical, functional, emotional, social, and spiritual needs.

What’s in the Toolkit

Target scarce resources to the patients most in need by developing appropriate referral criteria and building consult triggers into the electronic health record (EHR). Includes adult and pediatric referral criteria for inpatient palliative care.

CAPC Palliative Care Referral Criteria

Checklist of triggers for referral to a specialty palliative care team.

Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting

Screen hospitalized patients for unmet palliative care needs, and triage support interventions between the treating team and palliative care specialists. Journal of Palliative Medicine, 2011.

Implementing ICU Screening Criteria for Unmet Palliative Care Needs: A Guide for ICU and Palliative Care Staff
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Guidance on needs assessment, screening criteria selection, implementation planning, and evaluation.

EHR Strategies for the Palliative Care Team: A Town Hall Discussion

Webinar on building assessment and trigger protocols into the EHR.

Supportive and Palliative Care Indicators Tool (SPICT™)

Created by the University of Edinburgh to identify patients with unmet palliative care needs in both hospital and office settings.

Pediatric Palliative Care Referral Criteria
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General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.

Identifying patients in community settings is particularly challenging because functional/cognition status is rarely captured in claims or clinical data systems. Use this toolkit to find the population at risk for readmission, poor outcomes, preventable suffering, or mortality.

LACE Index Scoring Tool

Used to identify patients at high risk for readmission or death.

Charlson Comorbidity Index

Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.

Supportive and Palliative Care Indicators Tool (SPICT™)

Created by the University of Edinburgh to identify patients with unmet palliative care needs in both hospital and office settings.

Walter Prognostic Index

Online tool that predicts risk of death within one year of hospitalization, specific to patients aged 70+.

Sample Diagnoses Codes to Identify Patients Living with Serious Illness

Population health entities can use this list to proactively identify people with potentially unmet palliative care needs.

Communicating with Treating Clinicians about the Implications of Frailty
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Identifying patients with frailty who are at high risk for health care utilization and adverse outcomes.

Identifying Patients with Chronic Conditions in Need of Palliative Care in the General Population

Development of the NECPAL tool and preliminary prevalence rates in Catalonia. Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, et al. BMJ Supportive and Palliative Care, 2013.

Identifying Patients with Serious Illness: The Denominator Challenge

Using claims data to identify the population in need of palliative care. Kelley AS and Bollens-Lund E, Journal of Palliative Medicine, 2017.

Identifying the Right Patients for Specialty Palliative Care

Presentation examining criteria for palliative care services.

Patient Engagement Guide
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Identifying the population in need of palliative care, and working with patients and treating clinicians for effective relationships. Includes suggested phone scripts.

Predictive modeling of U.S. health care spending in late life

Demonstrates that prognostication is not an effective means of prospectively identifying a high-cost/high-need population. Einav, L., Finkelstein, A., Mullainathan, S. and Obermeyer, Z. Science, 2018.

Identifying Skilled Nursing Facility Residents Appropriate for Hospice or Comfort Care

A document with guidance and sample orders to assist nursing homes in identifying patients and residents with limited prognoses. INTERACT II.

ABCD Cultural Assessment Model

Guidance on how to gather culturally-relevant information from patients and families. Kagawa-Singer and Blackhall.

Guidance and case studies to find the right patients at the right time.

Proactive Patient Identification for Health Plans and ACOs: A Guide

Best practices in how to use data sources, such as claims or medical records, to identify patients who are most likely to benefit from palliative care.

Sample Diagnoses Codes to Identify Patients Living with Serious Illness

Population health entities can use this list to proactively identify people with potentially unmet palliative care needs.

Identifying Patients with Serious Illness: The Denominator Challenge

Using claims data to identify the population in need of palliative care. Kelley AS and Bollens-Lund E, Journal of Palliative Medicine, 2017.

Predictive modeling of U.S. health care spending in late life

Demonstrates that prognostication is not an effective means of prospectively identifying a high-cost/high-need population. Einav, L., Finkelstein, A., Mullainathan, S. and Obermeyer, Z. Science, 2018.

Pediatric Palliative Care Referral Criteria
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General palliative care referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses.

Charlson Comorbidity Index

Predicts risk of death within one year of hospitalization. Used by home-based palliative care programs to identify patients for enrollment.

Patient Engagement Guide
MEMBERS ONLY locked

Identifying the population in need of palliative care, and working with patients and treating clinicians for effective relationships. Includes suggested phone scripts.

Case Study: Moffit
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Integration of a patient-reported symptom assessment tool into the EHR and workflow. CAPC and the Accountable Care Learning Collaborative.

Identifying Patients in Home Health
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Poster summarizing factors used to identify palliative need immediately after hospitalization, when the opportunity to prevent unnecessary utilization is highest. OHSU and Brown University.

Advanced Illness and Frailty Value Sets

NIH's code sets that can be used to create identification algorithms. See Advanced Illness and Frailty value sets, stewarded by NCQA.

Best Practices in Initial Patient Outreach
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Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.

Best Practices in Initial Patient Outreach - Sample Recording
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Sample recruiter-patient audio exchange.

ABCD Cultural Assessment Model

Guidance on how to gather culturally-relevant information from patients and families. Kagawa-Singer and Blackhall.

Evidence-based resources for assessing pain, symptom burden, psychological and social needs, caregiver burden, and spiritual distress.

Revised Edmonton Symptom Assessment System (ESAS-r)

Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.

Pain Assessment Questions
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Recommended assessment questions to typify pain and inform pain management for patients with serious illness.

Pain Assessment and Documentation Tool (PADT)

Validated instrument to assess pain intensity and impact on function over time.

Wong-Baker FACES Pain Rating Scale

Illustrated pain scale for patients with cognitive impairment and children.

Condensed Memorial Symptom Assessment Scale (CMSAS)

Measures the frequency, severity, and distress associated with 32 symptoms.

Memorial Symptom Assessment Scale

Assessment of more than 30 symptoms; also quantifies severity.

NCCN Distress Thermometer

Assessment tool for symptom burden and impact on quality of life. National Comprehensive Cancer Network (NCCN), 2016.

PHQ-4 Validated Screening Tool for Anxiety and Depression

Brief (4-question) screening tool for anxiety and depression.

PHQ-9: Validated Screening Tool for Depression

Used to screen, diagnose and measure the severity of depression.

Palliative Performance Scale

Assesses the patient's functional abilities including ambulation, activity level, self-care ability, intake and consciousness.

ECOG Performance Status

Assess disease progression, impact on activities of daily living, and appropriate treatment and prognosis.

Karnofsky Performance Status Scale Definitions Rating (%) Criteria

Stratifies patients by level of functional ability. Like the PPS, the Karnofsky score can be used to predict survival.

AD8 Dementia Screening

Screens for early dementia, which is often missed by common assessment tools such as the Mini-Mental Status Examination.

Zarit Burden Interview (ZBI-12)

Self-reported caregiver assessment.

Peds QL

Modular approach to measuring health-related quality of life in both healthy children and those with acute and chronic health conditions.

Spiritual Screening Tool

Assessment for suffering, distress, disconnection, or spiritual pain. Supportive Care Coalition.

Help patients and families understand palliative care and request a consult when needed.

Patient Resources: GetPalliativeCare.org

Website for patients and families with definitions, relevant patient stories, resources, and a searchable database to find palliative care programs.

These resources can help teams assess and address social needs such as unsafe housing or food insecurity

Inclusive Clinical Encounters

The goal of this learning activity is to equip clinicians across all disciplines with the tools to foster effective and inviting clinical encounters with seriously ill patients.

Practicing Inclusive Clinical Encounters

This learning activity, Practicing Inclusive Clinical Encounters, will help clinicians integrate strategies for effective and inclusive clinical encounters into their daily practice.

Social Needs Screen

Assessment tool and resource list to address social risk factors.

Health Leads Screening Toolkit

Social needs screen including: social needs domains, best practices, recommended screening tool (in English and Spanish) and a library of clinically-validated and patient-centered questions.

CMS 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, and recommended for Medicare and Medicaid beneficiaries.

Addressing Social Determinants of Health through Screening and Resource Referrals

With social determinants of health (SDOH) being closely linked to health outcomes among populations historically exposed to health care disparities, the Ascension team is addressing barriers and needs of community members through the implementation of a systematic SDOH screening and resource referral process.

Improving operations and training clinical staff to identify, stratify, and meet the needs of patients living with serious illness at the population level. Includes 24 resources.
Tools to make the case for palliative care resources and financial partnerships, including the palliative care evidence base and downloadable tools for presenting the case. Includes 27 resources.
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 27 resources.

See all 47 Toolkits

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