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

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.

The Case for Community-Based Palliative Care

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-based palliative care, program profiles, and a case example to use with leadership.

Introduction to Palliative Care in the Community

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

Needs Assessment: Ensuring Successful Community-Based Palliative Care

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

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

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

Evaluating Models for Palliative Care in the Community

In this Virtual Office Hour, ask questions of expert faculty about community-based models of care, including staffing, financing, service partnerships, and measuring productivity.

Planning for Community-Based Care: Getting Started

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.

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

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

Program Design for Palliative Care Delivered in the Home

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

Home-Based Palliative Care: Program Design and Program Expansion

In this Virtual Office Hour, 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.

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

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

Palliative Care Leadership Centers™

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

Sample Mission Statement
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Shared by ProHEALTH Care Support.

Sample Palliative Care Scope of Practice for the Home-Based Team
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Shared by Interim HealthCare/CarePoint, 2017

Sample Organizational Structure Chart
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Shared by Sutter Health-Advanced Illness Management (AIM).

Staffing Models Inventory for Home-Based Palliative Care Programs
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Staffing models used by home-based programs. Center to Advance Palliative Care, 2018.

Telehealth Start-Up Guide

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

CCHP Unveils Telehealth Reimbursement Guide for Providers

Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.

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

Financing a Palliative Care Program

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

Building the Business Plan for Community-Based Palliative Care

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

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

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

Optimizing Billing Practices

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

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.

Hospices Providing Palliative Care

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.

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

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

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

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

Quick Tips: Hospice-Operated Palliative Care: 5 Building Blocks for a Strong Start
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Assists hospices operating community palliative care programs to understand five key steps to take before launching their program. Center to Advance Palliative Care, 2019.

Quick Tips: Hospice-Operated Palliative Care: Assessing Organizational Bandwidth for Community Palliative Care
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Checklist for assessing organizational capacity to launch a non-hospice palliative care service. Center to Advance Palliative Care, 2019.

Quick Tips: Hospice-Operated Palliative Care: Defining Boundaries and Building Cohesion
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Guidance for clarifying boundaries between hospice and palliative care services, and building internal cohesion. Center to Advance Palliative Care, 2019.

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

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.

Metrics Frequently Used in Home-Based Palliative Care Programs
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Excerpted from the Guide to Home-Based Program Design. Center to Advance Palliative Care, 2017.

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

Health IT Functionality and Reporting Checklist
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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

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

Population Stratification Considerations
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Guidance on dosing interventions based on patient risk.

Sample Eligibility and Consent Form
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Shared by Sutter Health-Advanced Illness Management (AIM).

Considerations for Referral to Program
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For referrers. Shared by OACIS/ Lehigh Valley Health Network.

Palliative Care Referral Assessment Worksheet
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For referrers. Shared by Optio Health Services.

Sample Enrollment and Disenrollment Protocols for Home-Based Palliative Care
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Shared by ProHEALTH Care Support.

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

Palliative Care Program Operations Definitions
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Shared by Interim HealthCare/CarePoint.

Provider Home Consultation
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Shared by Interim HealthCare/CarePoint.

Assessment and Treatment of Physical Emotional Symptoms
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Shared by Interim HealthCare/CarePoint.

Informed Consent
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Shared by Interim HealthCare/CarePoint.

Provider Counseling and Coordination
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Shared by Interim HealthCare/CarePoint.

Treatment and Care Planning
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Shared by Interim HealthCare/CarePoint.

Continuity of Care
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Shared by Interim HealthCare/CarePoint.

Significant Change in Condition
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Shared by Interim HealthCare/CarePoint.

Patient Self Determination
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Shared by Interim HealthCare/CarePoint.

Hospice Guidelines
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Shared by ProHEATH Care Support.

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

Tip Sheet: Marketing Home-Based Palliative Care to Potential Referrers
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Program Description & Welcome Page
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Shared by ProHEATH Care Support.

Program Marketing Brochure
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Shared by ProHEATH Care Support.

Physician Marketing Brochure
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Shared by Interim HealthCare/CarePoint.

Hospital ED Marketing Brochure
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Shared by Interim HealthCare/CarePoint.

Marketing Brochure for Referring Organizations
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On the benefits of partnering with the palliative care program. Shared by Interim HealthCare/CarePoint.

Palliative Care Consult Referral Request Marketing Brochure
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Shared by Interim HealthCare/CarePoint.

Assisted Living Facility Marketing Brochure
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Shared by Interim HealthCare/CarePoint.

Patient Marketing Brochure
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Shared by OACIS/Lehigh Valley Health Network.

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

"Palliative Care Can Help You": Program Marketing Brochure for Caregivers and Potential Patients
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Sample brochure shared by Hospice of Buffalo.

Health Care Proxy Pocket Card (For Patients)
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Shared by ProHEALTH Care Support.

Home Safety / Fall Prevention Brochure (For Patients)
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Shared by Optio Health Services.

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

Staffing Models Inventory for Home-Based Palliative Care Programs
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Staffing models used by home-based programs. Center to Advance Palliative Care, 2018.

Building and Supporting Effective Palliative Care Teams

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

Clinical Staff Evaluation Tool
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Shared by ProHEALTH Care Support.

Collaborative Practice Agreement
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Shared by Interim HealthCare/CarePoint.

Director of Palliative Care Position Description
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Shared by Interim HealthCare/CarePoint.

Palliative Care Service Line Medical Director Position Description
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Shared by Meridian Health.

Palliative Care Service Line Director Position Description
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Shared by Meridian Health.

Palliative Care Service Line Manager Position Description
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Shared by Meridian Health.

Palliative Care Nurse Practitioner Position Description
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Shared by Meridian Health.

Palliative Care Advanced Practice Nurse (APN) Position Description
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Shared by Interim HealthCare/CarePoint.

APN Written Delegation Protocol
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Shared by Interim HealthCare/CarePoint.

RN Care Coordinator (RNCC) Position Description
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Shared by Sutter Health-Advanced Illness Management (AIM).

Palliative Care Transition Care Coordinator Position Description
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Shared by Interim HealthCare/CarePoint.

Palliative Care Clinical Coordinator (RN) Position Description
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Shared by Meridian Health.

Telesupport RNCC Position Description
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Shared by Sutter Health-Advanced Illness Management (AIM).

After Hours Triage Nurse - Hospice Position Description
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Shared by Sutter Health-Advanced Illness Management (AIM).

Hospital Liaison Position Description
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Shared by Sutter Health-Advanced Illness Management (AIM).

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

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

Palliative Care Social Work Supervisor Position Description
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Shared by Meridian Health.

Palliative Care Social Worker Position Description
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Shared by Meridian Health.

AIM Transitions Medical Social Worker Position Description
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Shared by Sutter Health-Advanced Illness Management (AIM).

Social Worker (Palliative Outpatient) Position Description
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Shared by OACIS/Lehigh Valley Health Network.

Palliative Care Chaplain Position Description
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Shared by Meridian Health.

Palliative Care Secretary Position Description
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Shared by Meridian Health.

Palliative Care Data Analyst Position Description
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Shared by Meridian Health.

Volunteer Guidelines
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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.

Telehealth Start-Up Guide

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

CCHP Unveils Telehealth Reimbursement Guide for Providers

Information about The Center for Connected Health Policy's new provider resource on Medicare and Medicaid reimbursement for telehealth and mHealth.

Top Ten Tips Palliative Care Clinicians Should Know About Telepalliative Care

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.

Home Visit Checklist
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Shared by ProHEALTH Care Support.

New Patient Assessment Domains
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Excerpted from the Guide to Palliative Care in the Home.

Mileage Reimbursement Tool
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Shared by ProHEALTH Care Support.

Opioid Treatment Agreement
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Shared by Optio Health Services.

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

Institute for Healthcare Improvement, August 2017.