Patients who are neither hospitalized nor on hospice care need access to palliative care in a community clinic or office setting, such as a cancer center or dialysis unit. Such services may be delivered by physician groups or hospice- or home-health-based palliative care teams, or as extensions of an inpatient palliative care team and program.

Some office/clinic palliative care programs are embedded within another specialty clinic (for example, an oncology clinic), while others may share space within an existing clinic but operate independently; still others are geographically freestanding. Each model has operational and financial tradeoffs—learn more in the “Designing the Service” section of this toolkit.

What’s in the Toolkit

Engage stakeholders—patients and families, organizational leadership, referrers, and financial partners—to understand their priorities and guide program design.

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 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.

Clinic-based palliative care services are delivered using a number of different models depending upon patient need, organizational priorities, and referrer relationships.

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.

Office-Based Palliative Care Program Design

Designing and implementing an office-based palliative care program, including clinical model and operational considerations.

Specialty Palliative Care Delivery in the Clinic

Ask questions about developing an office- or clinic-based palliative care service, including factors such as administrative oversight, patient populations, services, staffing, and quality metrics for palliative care.

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

Office-Based Palliative Care Clinical Encounter Planning Checklist
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Steps to ensure high-quality, well-coordinated clinical care for the office-based interdisciplinary team.

Office-Based Palliative Care Administrative Planning Checklist
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Steps to ensure high-functioning administrative and operational practices for the office-based program.

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.

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.

Specialty Clinic/Primary Care Service Agreement
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Sample service agreement and scope of practice for embedded palliative care services. Shared by the John D. Dingell VA Medical Center.

Use these tools to design or update a sustainable business plan and budget for your clinic program.

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.

Financing a Palliative Care Program

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

Optimize your program’s billing practices to support financial viability.

Optimizing Billing Practices

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

Billing for Community-Based Palliative Care

In this Virtual Office Hour, ask questions about billing for services provided in the home, office, or long-term care setting.

Collect data on outcomes that matter to your program’s financial and clinical stakeholders—including patients—and that facilitate continuous quality improvement. Use these tools to identify measures aligned with the concerns of your stakeholders, collect the data, and apply data analytics 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.

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.

Clinic Patient Follow-Up Evaluation
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Phone script and visit follow-up evaluation tool, including symptom assessment and patient satisfaction survey. Shared by the University of California San Francisco, 2013.

Pediatric Family Bereavement Survey
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Satisfaction survey for bereaved families. Includes request for feedback on how to improve the service. Shared by Akron Children's Hospital, October 2008.

Palliative Care Program Performance Improvement Report (Sample)
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Sample executive summary of a year-end performance report, including service milestones and performance improvement indicators. Shared by OACIS Palliative Care, Lehigh Valley Health Network.

Referring Clinician Satisfaction Survey
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Assess satisfaction and generate feedback from referring providers. Shared by Froedtert Hospital.

Sample tools used by clinic-based palliative care teams to manage referrals, document patient visits, and maintain clinical quality.

Clinic Referral Intake Form (Sample)
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Intake form for the new palliative care clinic patient. Shared by Massachusetts General Hospital, 2012.

Clinic Referral Form (Sample)
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Referral form for new palliative care patients see in clinic. Shared by Massachusetts General Hospital, 2012.

Palliative Care Service Appointment Status and Check-Out Sheet (Sample)
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Check-out sheet including appointment status, next visit planning, testing requests, and recommended referrals. Shared by Massachusetts General Hospital, 2010.

Clinic Consultation Note Template
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Oncology clinic palliative care note template. Shared by UCSF Helen Diller Family Comprehensive Cancer Center, October 2008.

SMS History and Physical Form for APEX
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Template for standardized entry of H&P into the EHR, including all palliative care domains called for in the NCP Guidelines.

Client Patient Call Documentation Form
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Template documentation for a patient call to the clinic. Shared by Massachusetts General Hospital, 2012.

Prescribing Opioids: A Pocket Reference

Opioid pocket reference for providers including safe starting doses, equianalgesic chart, and standard dosing strengths. Center to Advance Palliative Care, 2019.

Standard: Non-Controlled Medication Refill
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Protocol for addressing requests for refills for non-controlled medications. Shared by the University of Alabama at Birmingham Supportive and Palliative Care Clinics.

Standard: Bereavement
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Sample standard for bereavement services for the palliative care team. Shared by the University of Alabama at Birmingham Supportive and Palliative Care Clinics.

Sample position descriptions for the clinic-based team.

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.