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.
Table of Contents to Home Health And Hospice Best Practice Resources

Resource Links: For All Patients

Resource Links: Hospice and Palliative Care

Caregiver Support
Cognitive Changes 
Community Resources
Disaster preparedness
Dyspnea Assessment and Management
Falls Prevention
Functional Status Assessment and Improvement
Immunizations - Flu and Pneumonia
Medication Reconciliation & Management
Pain Assessment and Management
Palliative Care – End of Life Continuum
Patient Education
Patient Engagement and Health Literacy
Readmissions/ Transitions of Care
Risk Assessment
Hospice Care Initiation
Pain Assessment and Management
Palliative Care – End of Life Continuum
Palliative Care Program Development
Patient Engagement in Palliative and Hospice
Caregiver Support
Hospice Quality Measurement
Spiritual Needs
Symptom Management in Hospice
Treatment Preferences in Hospice

Resource Links: Clinical Conditions

Resource Links: High Performance Agency

Depression Screening
Heart Failure
Joint Replacement
Pressure Ulcers
Quality and Reliability Improvement
Quality Reporting Requirements (see policy links)
Patient Experience
Patient Reported Outcomes
SBAR Communications
Value-based Purchasing

Links to Policy and Performance Reporting

Home Health Quality Reporting Program
Hospice Quality Reporting Requirements

For All Patients

Caregiver Support Cognitive Changes - Assessment and Management Community Resources Disaster Preparedness Dyspnea Assessment and Management Falls Prevention
Falls Risk Tools – See also Functional Status
Generic Falls Risk Assessment
Functional Status Assessment and Improvement
Immunization Tools
CDC Tools for Providers
Medication Management and Reconciliation Pain Assessment and Management
Pain Assessment Tools (see Pain module for more tools) 
The Faces Pain Scale-Revised or FPS-R  - patient visual
Verbal Descriptor Scale 
10 Point Scale
Wong-Baker FACES Pain Scale - patient visual for children
FLACC for assessment for young children (patient visual) 
Brief Pain Inventory (BPI)  and BPI User Guide
McGill Pain Inventory Short Form 
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)(staff observation)
Pain Assessment in Advanced Dementia (PAIN-AD) (staff observation) 
Symptom Distress Scale 
CNA Pain Assessment Tool (CPAT) 
Elderly Pain Caring Assessment 2 (EPCA-2) - Observational assessment
Memorial Symptom Assessment Scale (MSAS)
Non-Communicative Patient’s Pain Assessment Instrument (NOPPAIN) - Observational assessment
Discomfort Behavior Scale - Observational assessment
Checklist of Nonverbal Pain Indicators 

Patient Engagement and Health Literacy Readmission Prevention / Transitions of Care Risk Assessment

Clinical Interventions

Depression Screening and Management
Depression Screeing Tools
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.

Heart Failure Joint Replacement
Tools-See Functional Status
Pressure Ulcer Treatment and Prevention
Pressure Ulcer Prevention and Treatment
Pressure Ulcer Patient Education
Pressure Ulcer Tools
Braden Scale
Intervention Protocols For Braden Scale Subscales: nursing interventions linked to Braden Scale scores.
NPUAP Presentation on Risk Assessment tools and Approaches (2015)
NPUAP PUSH Tool for pressure ulcer measurement
National Pressure Ulcer Advisory Panel - PUSH Tool 3.0 (web version) 
High Performing Agencies
Quality Improvement and Reliability Value-Based Purchasing Patient Education
  Patient Experience Patient-Reported Outcomes
  • 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
Hospice Care Initiation Tools
MAHC 10 - Fall Risk Assessment Tool 
standardized questionnaire that scores the patient in 10 areas to come up with a risk level
PPS – Palliative Performance Scale (Copyright 2001 Victoria Hospice Society)
Braden Scale - A widely used tool to predict the risk of pressure ulcers. Six criteria are examined: Sensory perception; Moisture; Activity; Mobility; Nutrition and Friction and Shear.
ECOG and Karnofsky Performance Status Tools -
GCS – Glasgow Coma Scale aims to give a reliable, objective way of recording the conscious state of a person. Used in monitoring chronic patients in intensive care.
MNA® – Mini Nutritional Assessment – reflects the patient’s nutritional condition among other domains and is predictive of patient’s outcome (death or survival)
NYHA – New York Heart Association Functional Classification of Heart Failure - provides a simple way of classifying the extent of heart failure
Caregiver Support (link to home health)
Palliative Care/End of Life Palliative Care Program Development Patient Engagement in Hospice and Palliative Care  Spiritual Needs
  • National Palliative Care Resource Center – includes multiple needs assessment tools
  • Needs at the End of Life Screening Tool (NEST) at NPCRC– This tool is a numeric rating scale that addresses issues such as religious beliefs, sense of purpose, trust in health care professionals, and evaluation of care compared to the individual’s health care goals.
  • CAPC – Center to Advance Palliative Care “Policies and Tools for Hospital Palliative Care Programs” – a hospital specific document that includes a Spiritual Care Assessment tool.
  • FICA (acronym for the four aspects of healthy spiritual conversations between clinicians and patients) – Facilitates and encourages health care professionals to have spiritual conversations with patients and to identify spiritual issues patients face, spiritual distress, and patient’s spiritual resources of strength.
 Hospice Symptom Management
Edmonton Symptom Assessment Tool (ESAS) at NPCRC – This is a multi-symptom assessment tool used to evaluate for the presence and severity of symptoms
Hospice Treatment Preferences

Policy and Performance Reporting Requirements and Concepts

Home Health Quality Requirements and Reporting Hospice Quality Requirements and Reporting Palliative Care Quality Measures
Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.  
By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.
    Educate payers on opportunity to improve outcomes by more effectively caring for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.
    Support clinicians and staff to practice in teams and at the top of their licenses, train for excellence, and recognize achievement.