Patient Identification and Assessment

Diane E. Meier
Alison Silvers
Dana Lustbader
Implementation 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
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?
Population Addressed
Level of Evidence
Expert Opinion
What does this mean?