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 the long-term care palliative care program.

What’s in the Toolkit

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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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.

Conducting Focus Groups

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

Palliative Care in Long-Term Care Settings

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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Embedding Palliative Care in Nursing Homes: The OPTIMISTIC Experience

Last Updated: February 28, 2019

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

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Palliative Care in Long-Term Care

Last Updated: February 28, 2019

Webinar presentation on palliative care models in long-term care settings, February 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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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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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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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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Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End of Life Transitions

Last Updated: February 3, 2019

Journal of the American Geriatrics Society, 2016.

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