Patient Identification and Assessment

Diane E. Meier
Alison Silvers
Dana Lustbader
Technical Assistance Tool
March 2019

This resource is a toolkit for identifying patients with various physical, functional, emotional, social, and spiritual needs.

  • Patients and families living with serious illness have a range of needs beyond disease treatment, including support for functional limitation, pain and other symptoms, and caregiver burden.
  • This toolkit includes resources for inpatient providers, community-based providers, systems, plans, and accountable care organizations (ACOs).
  • It also includes clinical assessment tools and information for patients about palliative care.
  • Some of the resources in the toolkit are open-access and some are accessible by CAPC members only.
Posted to The Playbook on
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How can health care providers identify patients with various risks, such as readmission or death within a year of hospitalization?
  • How can providers determine eligibility for different kinds of care, such as home-based and palliative?
  • How can providers screen for dementia, pain, and social and spiritual needs?
Level of Evidence
Expert Opinion
What does this mean?