Resources, Training, Tools


ElevatingHome/VNAA 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- VTE prevention
Pressure Ulcers
Quality and Reliability Improvement
Quality Reporting Requirements (see policy links)
Patient Experience
Patient Reported Outcomes
SBAR Communications
Value-based Purchasing

VNAA RN Orientation Pathway Tool

Links to Policy and Performance Reporting
Home Health Quality Reporting Program
Hospice Quality Reporting Requirements
For All Patients

Caregiver Support
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 - Assessment and Management

Cognitive Changes in the Elderly - National Institutes of Health
Guidelines for Prevention and Treatment of Cognitive Impairment in the Elderly (2015)
American Geriatrics Society - guidelines, advocacy, patient information 
Mild Cognitive Impairment Patient Information on Medline Plus
Seven Stages of Dementia – Tools and Information

Community Resources
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 Provides comprehensive information on topics like financial support and available care options for aging adults.
Nutrition resources for seniors - from
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 Preparedness
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

Falls Prevention
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

Functional Status Assessment and Improvement
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

Medication Management and Reconciliation
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

Pain Assessment and Management
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)

Patient Engagement and Health Literacy
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

Readmission Prevention / Transitions of Care
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
Risk Assessment - 8P Project BOOST® Implementation Toolkit – Society for Hospital Medicine
National Palliative Care Resource Center – includes multiple symptom and needs assessment tools
Clinical Interventions

COPD Guidelines Review (MedScape, 2019)
VNA Alliance Information for Patients

Depression Screening and Management
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.

Heart Failure
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

 VTE After Joint Replacement
American Society for Hematology VTE Guideline (2018)
Updated Guidelines on Outpatient Anticoagulation (2013)
Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report (February 2016)

Pressure Ulcer Treatment and Prevention
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

Quality Improvement and Reliability
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)

Value-Based Purchasing
Home Health Value-Based Purchasing Model - CMS
Home Care Home Base Information on VBP
Catalyst for Payment Reform - VBP advocacy organization

Patient Education
AHRQ Patient Education Materials Assessment Tool (PEMAT) and User’s Guide
MedStar VNA - Patient & Caregiver Education Resource Center 

Patient Experience
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)

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. 

IHI SBAR (Situation, Background, Assessment, Recommendation) Toolkit – requires login
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) 

Palliative Care/End of Life
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

Palliative Care Program Development
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.
Issue Brief: Seven Ways State Policymakers Can Promote Palliative Care
Patient Engagement in Hospice and Palliative Care 
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

Spiritual Needs
National Palliative Care Resource Center – includes multiple symptom and needs assessment tools
UpToDate: 'Overview of spirituality in palliative care' (2019 evidence review) - fee applies

 Hospice Symptom Management
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

Hospice Treatment Preferences
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

Home Health Quality Requirements and Reporting
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 Requirements and Reporting
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 Quality Measures
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
Page last updated August 2019