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

A compilation of summary guidance for improving quality of life and access to palliative care specialists in long-term care settings.

Improving Palliative Care in Nursing Homes: A Report from CAPC
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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.

Palliative Care Implementation Guide Book

Principles and best practices for palliative care in nursing homes. Avila Institute of Gerontology, 2017.

Palliative Care Best Practices: A Guide for Long-term Care and Hospice

Explanation of what to do for residents of long-term care facilities. CIVHC, 2012

Palliative Care for People with Dementia: Why Comfort Matters in Long-Term Care

Care practices, tools, and case studies designed for front line staff at residentail care facilities. Shared by CaringKind, 2016.

Bringing Comfort to People with Advanced Dementia
Palliative Care in Your Nursing Home: Program Development and Innovation in Transitional Care

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.

Nursing Home Palliative Care Toolkit

Tools for developing palliative care programs in skilled nursing facilities. Created by The Nursing Home Palliative Care Collaborative of Rhode Island, 2014.

Palliative Care Issue Brief for Special Needs Plans and I-SNPs

Summary of key strategies for special needs plans, with a specific look at institutional special needs plans. CAPC for the SNP Alliance 2017

Palliative Care in Long-Term Care Settings

In this Virtual Office Hour, ask questions about strategic planning, program design, and program operations for palliative care in long-term care settings.

Use these resources to establish criteria for finding patients in need of palliative care services, and assessing their needs.

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.

Charlson Comorbidity Index

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

LACE Index Scoring Tool

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

Walter Prognostic Index

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

Revised Edmonton Symptom Assessment System (ESAS-r)

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

Spiritual Screening Tool

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

Early Identification and Communications in Long-Term Care

Summary of best practices in identifying those in need of palliative care, holding meaningful conversations, and collaborating with hospice when needed.

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.

Training Recommendations: A Guide to Online Courses for All Long-Term Care Staff Members
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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.

Recommended CAPC Courses for a PACE Interdisciplinary Team

Summary list of recommended CAPC clinical CE courses by role on a PACE team. Includes "on-boarding" and annual refresher recommendations.

Training Recommendations for Long-Term Care and ISNP Case Managers
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Recommended CAPC courses for long-term care case managers. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Certified Nursing Assistants
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Recommended CAPC courses for CNAs in long-term care organizations. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Intake Staff
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Recommended CAPC courses for long-term care intake staff. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Medical Directors, Physicians, and Advanced Practice Providers
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Recommended CAPC courses for providers working in long-term care. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Occupational Therapists, Physical Therapists, and Speech Language Pathologists
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Recommended CAPC courses for OT, PT, and SLP professionals working in long-term care. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Registered Nurses
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Recommended CAPC courses for RNs working in long-term care. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Social Workers
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Recommended CAPC courses for long-term care social workers. Center to Advance Palliative Care, 2019.

Training Recommendations for Long-Term Care Spiritual Care Providers
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Recommended CAPC courses for spiritual care providers working in long-term care. Center to Advance Palliative Care, 2019.

Tips for Staff Engagement in Training

How to engage staff in a clinical training initiative using CAPC's online courses.

CAPC Curriculum - Continuing Education Credits Overview

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.

Models and practices to optimize the services and supports for specialty palliative care teams.

Palliative Care Consultations in Nursing Homes and End of Life Hospitalizations

Study describing consultation programs and their impact on hospital transfers, across 4 states. Journal of Pain and Symptom Management 2016.

New Payment Models Provide Opportunities to Enhance Care in Nursing Homes

A background on payment and quality of care in nursing homes, and one team's success in reducing avoidable hospital transfers.

Palliative Care Provider Directory

Searchable directory of specialty palliative care providers, filtered by care setting.

Palliative Care Consultations in Nursing Homes: It Can (and Should) Be Done

Eric Widera, MD, reviews a study associating nursing home palliative care with decreased hospitalizations and burdensome transfers. GeriPal, 2016.

Skilled Nursing Facility (SNF) and Nursing Facility (NF) Billing and Coding
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Billing practices that reflect the complexity of palliative care services delivered in skilled nursing facilities and nursing homes. Center to Advance Palliative Care, 2020.

Hospice-Led Palliative Care

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

Palliative Care Transition Care Coordinator Position Description
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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.

Palliative Care Consent Form Example
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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.

Palliative Care Referral Fax
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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.

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

Telephonic Palliative Care During COVID-19

A document describing the impact of palliative care conversations with long-term care residents during COVID-19.

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.

Long-Term Care Profile: Hospice and Palliative Care of Greensboro
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Community-based palliative care program serving patients across multiple SNFs.

Long-Term Care Profile: New Jewish Home: Sarah Neuman
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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.

Palliative Care in Post-Acute Care Under Value-based Payment

Summary of two approaches to integrating palliative care into post-acute care. CAPC 2017

Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results

Findings from the Centers for Medicare and Medicaid Service's Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Health Affairs, 2017.

Long-Term Care Palliative Care Reference List
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Pivotal articles pertaining to palliative care delivery in long-term care organizations.