Resources, Training, Tools
ElevatingHome has identified tools, training programs, and reference material to support home-based care organizations in developing effective programs that move home care towards the Quadruple Aim: improved health of people and communities, added value, and satisfied patients and providers.
Use the links in the table of contents here navigate to specific types of resources - or browse the page to identify topics of interest. Most resources also include tools and training information and we recommend you start with Resources. Visit 'additional' for more information.
For All Patients
- National Alliance for Caregiving - Caregiver data, information, advocacy
- Roslyn Carter Institute for Caregiving - Caregiver training, education information, and best practices
- Family Caregiver Alliance - Caregiver policy, advocacy and support
- Cognitive Changes in the Elderly - National Institutes of Health
- Guidelines for Prevention and Treatment of Cognitive Impairment in the Elderly
- American Geriatrics Society - guidelines, advocacy, patient information
- Mild Cognitive Impairment Patient Information on Medline Plus
- Seven Stages of Dementia – Tools and Information
- Aging and Disability Resource Centers (ADRCs)
- Administration for Community Living (Aging Agency) - provides home and community-based services to older persons including transportation, adult day care, caregiver supports and health promotion programs.
- Assisted living resources from Caring.com. Provides comprehensive information on topics like financial support and available care options for aging adults.
- Nutrition resources for seniors - from Nutrition.gov
- The Senior Corps is a network of programs that tap the experience, skills, and talents of older citizens.
- Supplemental Nutrition Assistance Program (SNAP): eligibility and application information.
- National Association of Area Agencies on Aging (N4A): community based organizations that support elders and people with disabilities
- Disaster Safety for People with Disabilities: What to Do When Emergency Weather Strikes
- Disaster Preparedness for Seniors by Seniors
- Emergency Preparedness for People with Disabilities — Guide and Checklist
- Stanford Palliative Care Training Project includes a comprehensive training module on dyspnea assessment and management
- Preventing Older Adult Falls - Centers for Disease Control and Prevention - includes data and information on falls nd falls prevention
- CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults, 3rd Edition
- National Council on Aging – Falls Prevention Resource
- Stop Falls – Falls Prevention Center of Excellence - for patients, families, providers and researchers
- Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines - 2017 update
- Rehabilitation Measures Database
- Geriatric Examination Toolkit - includes links to many functional status tools
- Comprehensive Geriatric Assessment - 2018 review article
- Influenza Vaccination Information for Health Care Workers
- Immunization Action Coalition - CDC-funded patient and provider information
- Centers for Disease Control and Prevention Key Facts about Seasonal Flu Vaccine
- Centers for Disease Control and Prevention: Pneumococcal Vaccination
- CDC Immunization Tools for Providers
- Institute for Safe Medication Practices – includes FDA alerts, ‘no-crush’ and high-risk medication lists, and other tools
- Home Health Quality Improvement University-- free course on medication management; requires registration and includes continuing education credits.
- Medication Reconciliation at Transitions - Institute for Healthcare Improvement
- Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation - AHRQ
- Safe Medication Consumer Website – includes medication list template and other consumer information
- American Pain Society Guideline
- Improving the Quality of Care Through Pain Assessment and Management – from Patient Safety and Quality: An Evidence-Based Handbook for Nurses
- University of Iowa GeriatricPain Website – assessment, management, and QI tools
- The National Cancer Institute - PDQ Pain Information NCI offers detailed information on pain assessment and management for cancer related pain.
- Cancer Care Ontario - CCO is a Canadian Ontario government agency that has developed comprehensive symptom assessment and management guides for symptoms associated with cancer at end of life (applicable to other end of life conditions).
- City of Hope Pain &Palliative Care Resource Center very robust resource information.
- UpToDate - evidence reviews of pain assessment and management (fees may apply)
- AHRQ Health Literacy Universal Precautions Toolkit – Agency for Healthcare Research and Quality
- Health Resources and Services Administration Health Literacy
- Teach Back Method Training and Toolkit – part of AHRQ Health Literacy Universal Precautions training
- Patient Self-Management Best Practice Improvement Project - - HHQI
- Agency for Healthcare Quality and Research (AHRQ) – Preventing Avoidable Re-admissions
- AHRQ Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings
- CMS Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries
- Center for Health Care Quality and Payment Reform – Preventing Readmissions
- Improving Care Transitions Between Hospital and Home Health: A Home Health Model of Care Transitions
- Institute for Healthcare Improvement – Reduce Avoidable Readmissions
- National Transitions of Care Coalition
- Transitions of Care Resources and Tools - The Joint Commission
- Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration
- Risk Assessment - 8P Project BOOST® Implementation Toolkit – Society for Hospital Medicine
- National Palliative Care Resource Center – includes multiple symptom and needs assessment tools
- Depression Management BPIP – Home Health Quality Institute
- National Institute of Mental Health - Depression
- Geriatric Depression Scale (GDS) – – a 15 item scale asking patients to answer yes/no to a series of questions.
- Patient Health Questionnaire 2 (PHQ2) – - Utilized in OASIS (M1730) to quickly screen for depression.
- PHQ9 – Expanded version of the Patient Health Questionnaire that probes for specific possible symptoms.
- American Heart Association - Heart Failure
- UpToDate: Patient education: Heart Failure (The Basics) - 2019 Fees may apply
- Home Health Quality Improvement Program - Heart Failure Quality Improvement
- Qualidigm. Heart talk videos: Evidence-based educational video series about heart failure
- Prevention and Treatment of Pressure Ulcers / Injuries (2019 pending international guideline)
- WOCN 2016 Guideline for Prevention and Management of Pressure Injuries (2017 Executive Summary)
- AHRQ Pressure Ulcer resources
- Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care from the Agency for Healthcare Research and Quality.
- Cross-Setting Pressure Ulcer Measurement & Quality Improvement CMS webpage.
- National Pressure Ulcer Advisory Panel (NPUAP) , NPUAP White Papers and NPUAP Position Statements
- Wound, Ostomy and Continence Nurses
- Home Health Quality Improvement Institute: Patient education materials including Zone Tools
- Intermountain Healthcare Wound Care Patient Education Booklet: This is a helpful template for information to address in patient education materials.
- AAWC Professional and Patient/Caregiver Resources - linked to AAWC home page: materials in English and Spanish
|High Performing Agencies|
- Institute for Healthcare Improvement (IHI) "How to Improve" Model for Quality Improvement" - IHI QI Essentials Toolkit
- The Home Health Quality Improvement University is free with registration and includes online education with continuing education credits. Modules include: QAPI 101; PIPs to reduce hospitalizations; PIPs for medication management; PIPs for cardiovascular health
- IHI SBAR (Situation, Background, Assessment, Recommendation) Toolkit
- CMS Home Health Quality Reporting Progam
- Institute for Healthcare Improvement Getting Started Always Event Kit
- Recorded Webinar "It Takes a Village to Stay Home Safely" - Christiana Care Health System case conferencing approach to reducing readmissions.
- Creating High Reliability in Health Care Organizations (seminal article)
- Home Health Value-Based Purchasing Model - CMS
- Home Care Home Base Information on VBP
- Catalyst for Payment Reform - VBP advocacy organization
- AHRQ Patient Education Materials Assessment Tool (PEMAT) and User’s Guide
- MedStar VNA - Patient & Caregiver Education Resource Center
- Patient Experience with Care - Inventory of Improvement Resources (not home health specific)
- Patient Experience Observation Exercise – IHI exercise to improve quality of patient experience
- Institute for Innovation - summary of evidence on home health improvement of pt experience (2015)
- NIH PROMIS The Patient Reported Outcomes Measurement Information System tools measure what patients are able to do and how they feel by asking questions.
|Hospice and Palliative Care|
Hospice Care Initiation
- National Institute on Aging - Hospice and Palliative Care
- National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care (2018)
- Consumer Reports 'When to Start Hospice Care' (2017)
- Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life (2015). Institute of Medicine Report. Free downloadable PDF
- Medicare Advance Care Planning benefit rules
- Center to Advance Palliative Care and CAPC report on community based palliative care
- California Health Care Foundation’s Community-Based Palliative Care (CBPC) Resource Center. resources to support development of community based palliative care programs.
- Coalition for Compassionate Choices in California: Information and materials to assist organizations in developing community based palliative care programs.
- Respecting Choices – Advanced Care Planning: A program of the Gunderson Health System to support providers and patients in making decisions about end of life, and to get leadership buy in for a system wide initiative.
- The Conversation Project: A website that includes information and a kit to help people start talking about their end of life wishes
- Physician Orders for Life Sustaining Treatment (POLST): An approach to end-of-life planning based on conversations between patients, loved ones, and health care professionals
- National Palliative Care Resource Center – includes multiple symptom and needs assessment tools
- UpToDate: 'Overview of spirituality in palliative care' (2019 evidence review) - fee applies
- Cancer Care Ontario Symptom Management - Comprehensive symptom assessment and management guides for symptoms associated with cancer at end of life (applicable to other end of life conditions).
- National Institutes of Health PDQ® Cancer Information Summaries: Supportive and Palliative Care – evidence based recommendations for symptom management for multiple conditions
- Establishing Therapeutic Relationships - Nursing Best Practice Guideline - Registered Nurse Association of Ontario. July 2002, revised 2006.
- The Conversation Project- The Conversation Project encourages people to have conversations with their loved ones about end of life preferences, and provides tools to support those conversations.
- Physician Orders for Life Sustaining Treatment - POLST is a national initiative to promote end of life planning for people with serious illness or facility.
- Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life
- AAFP Hospice Care Resources
Policy and Performance Reporting Requirements and Concepts
- IMPACT Act of 2014
- CMS Measures Management Home Page
- CMS Home Health Star Ratings Information
- Home Health Compare Website
- Home health agency Medicare requirements and rules
- Hospice Quality Reporting Program
- Hospice Quality Reporting Measures used for Hospice Compare
- Hospice Compare
- Hospice program rules (Medicare)
- CMS Hospice Experience of Care Survey (CAHPS)
- Palliative Care Measures Menu: The California Health Care Foundation
- AAHPM Measuring What Matters
- National Quality Forum Palliative and End of Life Measures
- Joint Commission recommendations on palliative care measures
- Center to Advance Palliative Care (CAPC) recommendations for palliative care measures