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Rural Palliative Care - Operational Resources

The following tools and resources can assist health care providers with developing the organization structure to support delivery of palliaitve care services.

Action Plan Use. A grid to outline the goals and objectives of your palliative care project. Stratis Health (1-page Word doc)

Sample Action Plan. This example can help you understand how to complete your action plan. Stratis Health (3-page Word doc)

Structure and program design

Center to Advance Palliative Care tools. CAPC has tools to assist in designing, strengthening, and maintaining palliative care programs. Available to CAPC members only.

Collaborating with Community Partners for Palliative Care. Presented by Trudi Paulson, LISW, Partners in Aging Program, Fairview, Red Wing Health Services, and Kali Pachan, LSW, Palliative Care and Medical Home, Lakewood Health System. (53-minute audio file, recorded 01/11/11)

Contracting with Health Plans for Palliative Care Services. Presented by Barry Baines, MD, UCare, and Sandy Shellinger, RN, Allina Hospital and Clinics. (62-minute webinar, recorded 9/16/10) Handout (17-page PDF)

  • Palliative Care Blueprint. This draft toolkit was created for health plans that are considering developing a non-inpatient palliative care program or contracting with a vendor for such services. Alliance of Community Health Plans. (27-page PDF)
  • Palliative Care Contract Language. Insurance benefit contract language. Example from Allina. (2-page PDF)
  • Palliative Care Insurance Coverage Process for Community-Based Services. This process may be used as a reference for community agencies (such as home care, etc.) to develop a proposal for third party payment for palliative care visits not covered by current payment mechanisms. Stratis Health. (2-page PDF)

Health Care Home Certification - Minnesota Rural Palliative Care Collaborative Crosswalk. This tool outlines the health care homes standards against the work done by communities in the Initiative. (1-page PDF)

A National Framework and Preferred Practices for Palliative and Hospice Care Quality. The National Quality Forum has established a set of 38 best practices for improving palliative care programs outlined in Executive summary (3-page PDF)

Health care organizations that provide palliative care should offer the following services:

  • Comprehensive, 24-hour availability of palliative care through an interdisciplinary team of trained and certified palliative care professionals.
  • Timely communication of patients' goals and care plans in transfers between health care settings.
  • Assessments of patients' pain, anxiety and other symptoms that respect their cultural and individual preferences.
  • Social and spiritual care plans for patients.
  • Continuing professional education and support for caregivers on topics such as symptom management and communication.

One Agency’s Path to Palliative Care. As part of the Rural Palliative Care Networking Group, this webinar describes steps to establish a home health care based palliative care program along with explore opportunities, barriers, and funding options. Presented by Debbie Solomon, RN, MSN, CNP, Clinical Coordinator and Darcy Nelson, MSW, Hospice Coordinator, Fairview Lakes HomeCaring & Hospice (38-minute webinar, recorded 09/18/12)

Palliative Care in Long Term Care. This educational session is a set of three presentations from the Rural Palliative Care Networking Group. (82-minute audio file, recorded 9/21/10)

  • Our Palliative Care Story. Presented by Mary Miller-Hyland RN, BBA, NHA, Winona Senior Services / Lake Winona Manor. Handout (4-page PDF)
  • Palliative Care in the Care Center. Presented by Julie Benson, MD and Stacy Line, RN, ADON Care Center, Lakewood Health System. Handout (3-page PDF)
  • Fairview Red Wing Health Services Program. Presented by Jessica Hinkley-Reese, Fairview Red Wing Health Services, no handout available.

Taking Kids on Your Adult Palliative Care Program webinar. Presented by Jody Chrastek, Coordinator of Children’s Institute for Pain and Palliative Care. (53-minute webinar)

Vision, Mission, Values, Goals. Example from Waconia team (1-page Word doc)


CAPC measurement tools. The Center to Advance Palliative Care (CAPC) has a long list of measurement tools, including tools for using metrics to grow your program, customer metrics, operational metrics, and quality monitoring.

Measuring Outpatient Palliative Care: The Iowa Experience. Presented by Lori Bishop, RN CHPN, palliative care and hospice statewide executive director, Iowa Health Home Care. (61-minute webinar, recorded 05/19/11) Handout. (26-page PDF)

Palliative Care Aims and Measures. Example from Lake Winona Manor (2-page Word doc)

Palliative Care Patient and Family Satisfaction Survey. Example from Fairview Red Wing, Red Wing (2-page Word doc)

Care planning

Palliative Care Referral Criteria. Example from Fairview Red Wing Health Services (2-page Word doc)

Palliative Care vs. Hospice. Example from LifeCare Medical Center, Roseau (2-page Word doc)

Policies and guidelines

Case Management Follow-up Protocol. Example from Lakewood Health System, Staples (1-page Word doc)

Care Planning. Example from Lakewood Health System, Staples (html file)

Guidelines for Frequency of Visits for Palliative Care Patients. Example from LifeCare Medical Center. Roseau (1-page Word doc)

Palliative Care Guidelines. Example from Fairview Red Wing Health Services, Red Wing (3-page Word doc)

Palliative Care Referral. Example from Lakewood Health System, Staples (html file)

Performing Initial Assessments and Reassessments. Example from Lakewood Health System, Staples (html file)

Provision of Palliative Care. Example from Fairview Red Wing Health Services, Red Wing (3-page Word doc)

Referral Process Algorithm. Example from Winona Health (1-page Word doc)

Referrals to Palliative Care Policy. Example from LifeCare Medical Center, Roseau (1-page Word doc)

Scope of Care. Example from Lakewood Health System, Staples (html file)


Home Care, Hospice and Palliative Care Referral Form. Example from LifeCare Medical Center, Roseau (3-page Word doc)

MDS Chart Audit. Example from Lake Winona Manor, Winona (1-page Word doc)

Case studies of palliative care programs

These case studies outline existing rural palliative care programs, providing examples of different ways to structure services in the rural setting.

Developing a Rural Palliative Care Program: The Journey of Tomah Memorial Hospital. Mary Rezin, RN, BSN, CHPN, director Hospice Touch, discusses challenges and opportunities for palliative care in the rural community of Tomah, Wisconsin. She describes strategies to begin a successful program. (55-minute webinar, recorded 10/05/10) Handout (9-page PDF) Palliative Care Screening Tool (9-page PDF)

Fairview Red Wing. Presentation handout describing Red Wing's palliative care program. (4-page PDF)

Starting a Rural Palliative Care Program: A case example. Kathryn Borgenicht, MD, medical director at Bozeman Deaconess, shares the community's experience starting a program. (40-minute audio file, recorded 2/17/09) Handout (6-page PDF)

Wadena. Presentation handout describing Wadena's palliative care program. (2-page PDF) 


CAPC marketing tools. The Center to Advance Palliative Care (CAPC) has a long list of marketing materials.

Effectively Marketing a Palliative Care Program. CAPC provides general marketing communication guidance. Available to members only.

Brochure. Example from Lakewood Health System (2-page PDF)

Marketing flyer. A consumer flyer that describes Wadena's palliative care program. (1-page PDF)