Identification and Assessment Toolkit for Patients with Serious Illness

Diane E. Meier
Alison Silvers
Dana Lustbader
Implementation Tool
March 2019



Includes case studies, clinical assessment tools, and other resources for identifying and assessing the needs of patients with serious illness.


It is important to identify patients with serious illness in a timely manner to support their physical, functional, and social needs. This toolkit from the Center to Advance Palliative Care (CAPC) includes case studies, clinical assessment tools, and other resources for providers, health plans, and accountable care organizations (ACOs) to identify and assess the needs of people with serious illness and their caregivers.

About this Tool

The toolkit contains resources for:

  • Inpatient providers to develop appropriate referral criteria and build electronic health record capabilities to identify patients in need of palliative care;

  • Community-based providers to find populations at risk for poor outcomes at home or in the community; and

  • Health systems, health plans, and ACOs to proactively identify and engage patients most in need.

The evidence-based clinical assessment tools included in this toolkit – such as the Charlson Comorbidity Index and the PHQ-9 – assess things like pain, symptom burden, psychological and social needs, caregiver burden, and spiritual distress. Note, some of the resources in the toolkit are open access and some are accessible by CAPC members only.


Organizations can use the resources in this toolkit to design identification and assessment protocols when caring for people with serious illness.

Posted to The Playbook on