Designing a Home-Based Palliative Care Program

Last Reviewed: March 4, 2019

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.

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.

What’s in the Toolkit

Engage stakeholders—patients and families, organizational leadership, referrers, and financial partners—to guide program design that is aligned with their priorities.

National Consensus Project for Quality Palliative Care, 4th edition

Last Updated: January 29, 2019

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.

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Introduction to Palliative Care in the Community

Last Updated: January 15, 2015

Defining community-based palliative care: which patients need it, how it is delivered, and how it differs from inpatient palliative care.

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Needs Assessment: Ensuring Successful Community-Based Palliative Care

Last Updated: January 15, 2015

Evaluating patient need, service requirements, care settings, and stakeholder priorities for the community-based palliative care program.

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Community-Based Palliative Care Needs Assessment and Decision-Making Tool

Last Updated: January 29, 2019

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.

Community Toolbox: Conducting Focus Groups

Last Updated: March 29, 2019

Comprehensive instructions and tools for conducting focus groups during a needs assessment. Published by Community Tool Box.

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Evaluating Models for Palliative Care in the Community

Ask questions of expert faculty about community-based models of care, including staffing, financing, service partnerships, and measuring productivity.

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Planning for Community-Based Care: Getting Started

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.

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Home-based palliative care models are designed to match patient need, organizational priorities, and referrer relationships.

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Palliative Care in the Home: A Guide to Program Design (PDF Download)

Last Updated: March 1, 2019

Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.

Palliative Care in the Home: A Guide to Program Design (Purchase Link for Non-Members)

Last Updated: February 14, 2019

Essential reference for starting home-based palliative care, including design principles and profiles of sustainable home-based programs.

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Program Design for Palliative Care Delivered in the Home

Last Updated: October 17, 2016

Translating needs assessment into service design for the community-based palliative care program.

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Home-Based Palliative Care: Program Design and Program Expansion

Ask questions about all things home-based: developing a program, operational and management topics for home-based palliative care services, and building partnerships to expand the program.

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Palliative Care Partnerships: Leveraging Collaboration to Improve Access to Community Based Palliative Care

Last Updated: August 11, 2019

Establishing referral partnerships to address gaps in care for palliative care patients.

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Palliative Care Leadership Centers™

Last Updated: June 4, 2019

Palliative Care Leadership Centers (PCLC) offer hospitals two days of in-person, customized operational training and one year of mentoring.

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Sample Mission Statement

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

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Sample Palliative Care Scope of Practice for the Home-Based Team

Last Updated: February 25, 2019

Shared by Interim HealthCare/CarePoint, 2017

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Sample Organizational Structure Chart

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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Staffing Models Inventory for Home-Based Palliative Care Programs

Last Updated: February 3, 2019

Staffing models used by home-based programs. Center to Advance Palliative Care, 2018.

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Telehealth Start-Up Guide

Last Updated: February 3, 2019

Key components of telehealth service delivery, especially in a home-based palliative care program.

Tools to design a sustainable business plan and budget for your home-based program.

Funding a Palliative Care Program

Last Updated: March 4, 2019

Toolkit for building a business plan and budget, forming financial partnerships, and operating the program efficiently.

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Building the Business Plan for Community-Based Palliative Care

Last Updated: November 12, 2015

Building a budget and a business plan for the community-based program. Includes business planning tools.

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How to Build and Pay for Home-Based Palliative Care: The ProHEALTH Experience

Last Updated: August 11, 2019

Presentation on business planning and financial sustainability for the home-based program.

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Optimizing Billing Practices

Last Updated: March 4, 2019

Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.

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Many hospices offer palliative care as a separate business line. Use these tools to navigate palliative care program start-up and operations.

Hospice-Led Palliative Care

Designing high-quality, sustainable palliative care as a separate business line.

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Hospices Providing Palliative Care

Ask questions on Virtual Office Hours 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.

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Hospices as Providers of Community-Based Palliative Care: Planning Your Service Strategically

Last Updated: August 11, 2019

Considerations for the hospice before starting a non-hospice palliative care service line. Webinar presentation.

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Hospices as Providers of Community-Based Palliative Care: Demystifying the Differences

Last Updated: August 11, 2019

Differentiating hospice and palliative care services and eligibility. Webinar presentation.

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Quick Tips: Hospice-Operated Palliative Care: 5 Building Blocks for a Strong Start

Last Updated: February 28, 2019

Assists hospices operating community palliative care programs to understand five key steps to take before launching their program. Center to Advance Palliative Care, 2019.

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Quick Tips: Hospice-Operated Palliative Care: Assessing Organizational Bandwidth for Community Palliative Care

Last Updated: February 28, 2019

Checklist for assessing organizational capacity to launch a non-hospice palliative care service. Center to Advance Palliative Care, 2019.

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Quick Tips: Hospice-Operated Palliative Care: Defining Boundaries and Building Cohesion

Last Updated: February 28, 2019

Guidance for clarifying boundaries between hospice and palliative care services, and building internal cohesion. Center to Advance Palliative Care, 2019.

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Quick Tips: Hospice-Operated Palliative Care: Designing the Community Palliative Care Program

Last Updated: March 22, 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.

Measurement Best Practices

Last Updated: March 4, 2019

Use this toolkit to select program measures that demonstrate value to stakeholders and support quality care delivery. Overcome common measurement obstacles and synthesize program data.

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Metrics Frequently Used in Home-Based Palliative Care Programs

Last Updated: March 1, 2019

Excerpted from the Guide to Home-Based Program Design. Center to Advance Palliative Care, 2017.

National Palliative Care Registry™

Last Updated: February 27, 2019

A publicly available national database of palliative care programs and operational metrics, free of charge to all palliative care programs. Submit program data to receive reporting and to track program growth and capacity over time. Compare your program to peers to help make the case for adequate staffing and program quality.

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Recommended Program Measures and CAPC Measurement Toolkit

Last Updated: February 3, 2019

Recommended measures for inpatient and community palliative care programs, and using data to demonstrate value and perform continuous quality improvement.

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Health IT Functionality and Reporting Checklist

Last Updated: February 3, 2019

List of HIT capabilities needed by palliative care programs for population management and data monitoring.

Identify appropriate patients for your program, and assess their palliative care needs.

Patient Identification and Assessment

Last Updated: March 4, 2019

Toolkit for finding the right patients at the right time to address gaps in care.

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Population Stratification Considerations

Last Updated: February 3, 2019

Guidance on dosing interventions based on patient risk.

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Sample Eligibility and Consent Form

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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Considerations for Referral to Program

Last Updated: February 3, 2019

For referrers. Shared by OACIS/ Lehigh Valley Health Network.

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Palliative Care Referral Assessment Worksheet

Last Updated: February 3, 2019

For referrers. Shared by Optio Health Services.

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Sample Enrollment and Disenrollment Protocols for Home-Based Palliative Care

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

Protocols used by home-based programs to standardize team practice.

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Palliative Care Program Operations Definitions

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Provider Home Consultation

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Assessment and Treatment of Physical Emotional Symptoms

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Informed Consent

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Provider Counseling and Coordination

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Treatment and Care Planning

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Continuity of Care

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Significant Change in Condition

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Patient Self Determination

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Care of the Imminently Dying

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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End-of-Life Care

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Hospice Guidelines

Last Updated: February 3, 2019

Shared by ProHEATH Care Support.

Sample materials to explain program benefits and services to patients, families, and referrers.

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Tip Sheet: Marketing Home-Based Palliative Care to Potential Referrers

Last Updated: March 4, 2019

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Program Description & Welcome Page

Last Updated: February 3, 2019

Shared by ProHEATH Care Support.

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Program Marketing Brochure

Last Updated: February 3, 2019

Shared by ProHEATH Care Support.

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Physician Marketing Brochure

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Hospital ED Marketing Brochure

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Marketing Brochure for Referring Organizations

Last Updated: February 3, 2019

On the benefits of partnering with the palliative care program. Shared by Interim HealthCare/CarePoint.

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Palliative Care Consult Referral Request Marketing Brochure

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Assisted Living Facility Marketing Brochure

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Patient Marketing Brochure

Last Updated: February 3, 2019

Shared by OACIS/Lehigh Valley Health Network.

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Patient Marketing Brochure

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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"Palliative Care Can Help You": Program Marketing Brochure for Caregivers and Potential Patients

Last Updated: April 26, 2019

Sample brochure shared by Hospice of Buffalo.

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Health Care Proxy Pocket Card (For Patients)

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

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Home Safety / Fall Prevention Brochure (For Patients)

Last Updated: February 3, 2019

Shared by Optio Health Services.

Tools to support team development and sample job descriptions for a home-based program.

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Staffing Models Inventory for Home-Based Palliative Care Programs

Last Updated: February 3, 2019

Staffing models used by home-based programs. Center to Advance Palliative Care, 2018.

Building and Supporting Effective Palliative Care Teams

Last Updated: March 4, 2019

Hire and onboard your staff, manage program operations, and ensure a healthy high-functioning team using this toolkit.

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Clinical Staff Evaluation Tool

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

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Collaborative Practice Agreement

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Director of Palliative Care Position Description

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Palliative Care Service Line Medical Director Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Service Line Director Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Service Line Manager Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Nurse Practitioner Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Advanced Practice Nurse (APN) Position Description

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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APN Written Delegation Protocol

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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RN Care Coordinator (RNCC) Position Description

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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Palliative Care Transition Care Coordinator Position Description

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

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Palliative Care Clinical Coordinator (RN) Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Telesupport RNCC Position Description

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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After Hours Triage Nurse - Hospice Position Description

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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Hospital Liaison Position Description

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

Making the Case for Social Workers as Integral Members of the Home-Based Palliative Care Team

Last Updated: August 11, 2019

Presentation on role clarity in the home-based palliative care IDT.

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Palliative Care Social Work Supervisor Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Social Worker Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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AIM Transitions Medical Social Worker Position Description

Last Updated: February 3, 2019

Shared by Sutter Health-Advanced Illness Management (AIM).

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Social Worker (Palliative Outpatient) Position Description

Last Updated: February 3, 2019

Shared by OACIS/Lehigh Valley Health Network.

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Palliative Care Chaplain Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Secretary Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Palliative Care Data Analyst Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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Volunteer Guidelines

Last Updated: February 3, 2019

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.

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Telemedicine and Palliative Care

Last Updated: February 3, 2019

Basic principles and opportunities for using telemedicine to extend palliative care program capacity.

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Telehealth Start-Up Guide

Last Updated: February 3, 2019

Key components of telehealth service delivery, especially in a home-based palliative care program.

Top Ten Tips Palliative Care Clinicians Should Know About Telepalliative Care

Last Updated: July 29, 2019

Provides a review of the current evidence for telepalliative care and potential applications and practical tips for using the technology.

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Working in the home can be unpredictable. Use these tools to ensure safe, respectful interactions in patients’ homes.

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Home Visit Checklist

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

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New Patient Assessment Domains

Last Updated: February 3, 2019

Excerpted from the Guide to Palliative Care in the Home.

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Mileage Reimbursement Tool

Last Updated: February 3, 2019

Shared by ProHEALTH Care Support.

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Opioid Treatment Agreement

Last Updated: February 3, 2019

Shared by Optio Health Services.

Interpreter Services

Last Updated: February 3, 2019

Example of a company that offers language interpretation services for their patients in the home. CAPC does not endorse a particular interpretation service.

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Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities

Last Updated: February 3, 2019

Institute for Healthcare Improvement, August 2017.

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