Designing a Long-Term Care Palliative Care Program

Last Reviewed: March 4, 2019

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

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.

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LTC Learning Pathways: A Guide to Online Courses for All LTC Staff Members

Last Updated: May 30, 2019

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.

Online Clinical Training Courses For All Clinicians

Last Updated: August 16, 2019

Online training curriculum for all specialties and disciplines to strengthen their care of patients living with serious illness. Free continuing education credits for all, and physicians receive ABIM MOC points for select courses.

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CAPC Curriculum - Continuing Education Credits Overview

Last Updated: August 16, 2019

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.

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Long-Term Care Learning Pathways: Case Managers

Last Updated: May 21, 2019

Recommended CAPC courses for long-term care case managers. Center to Advance Palliative Care, 2019.

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Long- Term Care Learning Pathways: Certified Nursing Assistants

Last Updated: May 21, 2019

Recommended CAPC courses for CNAs in long-term care organizations. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Intake Staff

Last Updated: May 21, 2019

Recommended CAPC courses for long-term care intake staff. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Medical Directors, Physicians, and Advanced Practice Providers

Last Updated: May 21, 2019

Recommended CAPC courses for providers working in long-term care. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Occupational Therapists, Physical Therapists, and Speech Language Pathologists

Last Updated: May 21, 2019

Recommended CAPC courses for OT, PT, and SLP professionals working in long-term care. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Registered Nurses

Last Updated: May 21, 2019

Recommended CAPC courses for RNs working in long-term care. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Social Workers

Last Updated: May 21, 2019

Recommended CAPC courses for long-term care social workers. Center to Advance Palliative Care, 2019.

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Long-Term Care Learning Pathways: Spiritual Care Providers

Last Updated: May 21, 2019

Recommended CAPC courses for spiritual care providers working in long-term care. Center to Advance Palliative Care, 2019.

How to conduct a comprehensive assessment to determine the why, what and how of your LTC palliative care program. Engage stakeholders—patients and families, organizational leadership, and financial partners—to guide program design.

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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National Consensus Project for Quality Palliative Care, 4th edition

Last Updated: February 3, 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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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.

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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.

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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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Patient population, staffing mix, and service components all contribute to program design, which is guided by information from your needs assessment.

Online Operational Courses for Palliative Care Teams

Last Updated: October 16, 2019

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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.

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Improving Palliative Care in Nursing Homes: A Report from CAPC

Last Updated: February 3, 2019

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

Last Updated: February 3, 2019

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

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

Last Updated: February 3, 2019

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

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Palliative Care in Your Nursing Home: Program Development and Innovation in Transitional Care

Last Updated: February 3, 2019

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.

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Nursing Home Palliative Care Toolkit

Last Updated: February 3, 2019

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

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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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Hospice-Led Palliative Care

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

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Embedding Palliative Care in Nursing Homes: The OPTIMISTIC Experience

Last Updated: August 11, 2019

Case study webinar presentation from Dr. Kathleen Unroe, August 2015.

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Palliative Care in Long-Term Care

Last Updated: August 11, 2019

Webinar presentation on palliative care models in long-term care settings, February 2015.

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Good Palliative Care Requires Good Long-Term Care: A Medicare Strategy To Strengthen Both

Last Updated: February 3, 2019

Key elements of a care plan for Medicare beneficieries with functional limitations that coordinates services across the continuum of long-term care. Health Affairs Blog, 2014.

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Estimate start-up costs, operational costs, and reimbursement for the long-term care palliative care 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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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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Commonly Used ICD-10 Codes for the Palliative Care Program

Last Updated: February 3, 2019

Common ICD-10 codes for palliative care patient encounters. Center to Advance Palliative Care, 2018

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Setting-Based Evaluation and Management Table

Last Updated: February 3, 2019

E/M codes by setting and unit of time. Center to Advance Palliative Care, 2018.

Guidance and sample job descriptions for staffing the specialty palliative care team.

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 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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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 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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Palliative Care Chaplain Position Description

Last Updated: February 3, 2019

Shared by Meridian Health.

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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Long-Term Care Palliative Care Dashboard Example

Last Updated: May 21, 2019

Sample tool used to consolidate program information and demonstrate the value of the service. Palliative Care Associates, a program of Hospice and Palliative Care of Greensboro, August 2018.

National Palliative Care Registry™

Last Updated: April 20, 2019

The National Palliative Care Registry is building a profile of palliative care teams, operations, and service delivery. The Registry is free and open to all palliative care programs.

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A spectrum of palliative care models exists to meet patient needs in long-term care settings.

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Long-Term Care Profile: Hospice and Palliative Care of Greensboro

Last Updated: March 27, 2019

Community-based palliative care program serving patients across multiple SNFs.

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

Last Updated: May 21, 2019

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.

Integrating Palliative Care Into Nursing Homes: Challenges and Opportunities

Last Updated: February 3, 2019

Factors impacting palliative care growth, examples of delivery models, and policy recommendations. Health Affairs Blog, 2013.

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National Palliative Care Registry™

Last Updated: April 20, 2019

The National Palliative Care Registry is building a profile of palliative care teams, operations, and service delivery. The Registry is free and open to all palliative care programs.

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Mapping Community Palliative Care

Last Updated: March 4, 2019

Mapping Community Palliative Care is a project of the Center to Advance Palliative Care (CAPC), in collaboration with the National Coalition for Hospice and Palliative Care.

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Practical resources for delivering palliative care in long-term care settings.

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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Palliative Care Consent Form Example

Last Updated: May 21, 2019

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.

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Palliative Care Referral Fax

Last Updated: May 21, 2019

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.

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

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Palliative Care Office Flyer

Last Updated: May 21, 2019

Used to explain palliative care to residents and their families. Shared by Palliative Care Associates, a program of Hospice and Palliative Care of Greensboro, 2018.

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Assisted Living Facility Marketing Brochure

Last Updated: February 3, 2019

Shared by Interim HealthCare/CarePoint.

CAPC Handout for Patients and Families

Last Updated: August 16, 2019

Available on GetPalliativeCare.org, this handout contains patient and family-focused frequently asked questions about palliative care.

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The impact of palliative care on quality and hospital utilization measures for long-term care residents.

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

Last Updated: February 3, 2019

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

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

Last Updated: February 3, 2019

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

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Large Increases In Spending On Postacute Care In Medicare Point To The Potential For Cost Savings In These Settings

Last Updated: May 21, 2019

Chandra A, Dalton MA, Holmes J. Large Increases in Spending on Post-Acute Care in Medicare point to the Potential for Cost Savings in these Settings. Health Aff. 2013;32(5):864-872.

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Long-Term Care Palliative Care Reference List

Last Updated: May 21, 2019

Pivotal articles pertaining to palliative care delivery in long-term care organizations.

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