Patient Identification and Assessment

Last Reviewed: March 4, 2019

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.

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CAPC Palliative Care Referral Criteria

Last Updated: February 3, 2019

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

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

Last Updated: February 3, 2019

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.

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Implementing ICU Screening Criteria for Unmet Palliative Care Needs: A Guide for ICU and Palliative Care Staff

Last Updated: February 3, 2019

Guidance on needs assessment, screening criteria selection, implementation planning, and evaluation.

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

Last Updated: August 11, 2019

Webinar on building assessment and trigger protocols into the EHR.

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Supportive and Palliative Care Indicators Tool (SPICT™)

Last Updated: February 3, 2019

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

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Pediatric Palliative Care Referral Criteria

Last Updated: February 3, 2019

General referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses. Center to Advance Palliative Care, updated 2016.

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

Last Updated: February 3, 2019

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

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Charlson Comorbidity Index

Last Updated: February 3, 2019

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

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Clinical Triggers for PCMH Referral to Palliative Care

Last Updated: February 3, 2019

Listing of diagnostic criteria and patient/family circumstances that indicate a need for referral to palliative care. Developed by a Performing Provider System working to transform primary care in New York State.

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Supportive and Palliative Care Indicators Tool (SPICT™)

Last Updated: February 3, 2019

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

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Walter Prognostic Index

Last Updated: February 3, 2019

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

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Comprehensive ICD-10 Codes to Capture Patients with Serious Illness

Last Updated: May 6, 2019

Set of diagnoses codes that can be used to identify those with potential serious illness. Additional screening criteria, such as utilization patterns, should be applied.

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Communicating with Treating Clinicians about the Implications of Frailty

Last Updated: February 3, 2019

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

Last Updated: February 3, 2019

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.

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Identifying Patients with Serious Illness: The Denominator Challenge

Last Updated: February 3, 2019

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

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Identifying the Right Patients for Specialty Palliative Care

Last Updated: August 11, 2019

Presentation examining criteria for palliative care services.

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Patient Engagement Guide

Last Updated: May 8, 2019

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

Last Updated: February 3, 2019

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.

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

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Proactive Identification for Health Plans and ACOs: A Guide

Last Updated: February 25, 2019

Why proactive identification is important, how to build an algorithm, recommended first steps, and practical tips.

Identifying Patients with Serious Illness: The Denominator Challenge

Last Updated: February 3, 2019

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

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

Last Updated: May 6, 2019

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.

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Sample Identification and Eligibility Criteria for Home-Based Palliative Care

Last Updated: May 6, 2019

How diagnosis code, utilization, and risk score can be used to proactively identify members for home-based palliative care services. Includes ICD-10 and HCPCS codes to use, and which can serve as exclusion criteria. Sample criteria used by Blue Shield of California.

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Sample Screening Tool for Home-Based Palliative Care

Last Updated: May 6, 2019

Sample Blue Shield of California tool for determining whether a member is eligible for home-based palliative care services. Completion of this screen by a case manager or other clinical staff can assist in linking members and patients with available services.

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Pediatric Palliative Care Referral Criteria

Last Updated: February 3, 2019

General referral criteria for children with serious illness, and for specific diseases including cancer and pulmonary, genetic, neurologic, metabolic, and other diagnoses. Center to Advance Palliative Care, updated 2016.

Charlson Comorbidity Index

Last Updated: February 3, 2019

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

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Comprehensive ICD-10 Codes to Capture Patients with Serious Illness

Last Updated: May 6, 2019

Set of diagnoses codes that can be used to identify those with potential serious illness. Additional screening criteria, such as utilization patterns, should be applied.

MEMBERS ONLY locked

Patient Engagement Guide

Last Updated: May 8, 2019

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

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Case Study: Moffit

Last Updated: June 14, 2019

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

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Identifying Patients in Home Health

Last Updated: May 30, 2019

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

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

Revised Edmonton Symptom Assessment System (ESAS-r)

Last Updated: January 29, 2019

Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Edmonton Zone Regional Palliative Care Program, 2010.

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Pain Assessment Questions

Last Updated: January 29, 2019

Recommended assessment questions to typify pain and inform pain management for patients with serious illness. Center to Advance Palliative Care, 2015.

Pain Assessment and Documentation Tool (PADT)

Last Updated: February 3, 2019

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

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Wong-Baker FACES Pain Rating Scale

Last Updated: February 1, 2019

Illustrated pain scale for patients with cognitive impairment and children.

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Condensed Memorial Symptom Assessment Scale (CMSAS)

Last Updated: February 3, 2019

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

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Memorial Symptom Assessment Scale

Last Updated: February 3, 2019

Assessment of more than 30 symptoms; also quantifies severity.

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NCCN Distress Thermometer

Last Updated: January 29, 2019

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

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PHQ-4: Validated Screening Tool for Anxiety and Depression

Last Updated: January 29, 2019

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

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PHQ-9: Validated Screening Tool for Depression

Last Updated: February 25, 2019

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

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Palliative Performance Scale

Last Updated: February 3, 2019

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

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ECOG Performance Status

Last Updated: February 3, 2019

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

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Karnofsky Performance Status Scale Definitions Rating (%) Criteria

Last Updated: February 3, 2019

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

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AD8 Dementia Screening

Last Updated: February 3, 2019

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

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Short Form Zarit Burden Interview (ZBI-12)

Last Updated: February 3, 2019

Self-reported caregiver assessment.

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Peds QL

Last Updated: February 3, 2019

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

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CMS Accountable Health Communities Screening for Health-Related Social Needs

Last Updated: February 3, 2019

Identifies unmet need in housing, food, transportation, utilities, and safety. Developed by CMS for the Accountable Health Communities model.

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Health Leads Screening Toolkit

Last Updated: February 3, 2019

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.

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Spiritual Screening Tool

Last Updated: January 29, 2019

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

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Social Determinants of Health Screenings

Last Updated: February 3, 2019

Two-tiered assessment screening program developed by Montefiore Health System to measure social determinants of health.

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

Patient Resources: GetPalliativeCare.org

Last Updated: February 25, 2019

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

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