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Adopt a bundled payment model for home-based and outpatient palliative care.

Assess the needs needs of family caregivers and provide them with training and resources to support the care needs of seriously ill members.

Caregivers of people with serious illness are often overwhelmed and experience significant levels of stress and burden, which can directly impact their ability to provide quality support to the people in their care. Currently, most specialty palliative care teams address some caregiver needs through the team's social worker, but often these supports are not comprehensive and/or are highly dependent on individual social worker knowledge, skills, and competing priorities.


Whether administered by a health plan itself or through requirements for contracted palliative care teams and other providers, offering a more comprehensive and consistent additional layer of support to family caregivers has the potential to improve member outcomes. These outcomes may include reducing emergency room visits and hospitalizations, addressing medication-related issues, and ultimately, improving member satisfaction. Supported caregivers also contribute to helping members stay at home, thereby reducing the need for skilled nursing facility placement. 


Additionally, caregiver support programs provide the added benefit of improving outcomes for the caregiver, who might also be a member. This includes a decrease in caregiver depression and anxiety, prevention of injuries, and better management of the caregiver’s own chronic conditions. 


Caregiver support can manifest in various forms tailored to the specific needs of caregivers. This may include resource navigation and problem solving, emotional support and counseling, social-emotional skills training, medical skills training, respite, financial aid opportunities, and bereavement support. 



At the very least, start here


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Strive for excellence

Action Items

At the very least, start here

Ensure the health plan adopts a structured approach to supporting family caregivers of seriously ill members. Family caregiver support can be delivered by palliative care providers, community organizations, or with health plan internal resources. This support could include assessment, navigation, medical and non-medical skills training, and respite. 

Require contracted palliative care providers to have a structured and comprehensive approach to supporting family caregivers. Consider the effort required to do this work when calculating payment amount for palliative care providers.

Ensure that family caregiver support resources, whether delivered by the palliative care team or other partners, are cataloged and easily accessible to caregivers and all relevant contracted providers.

Assessment Tools

Caregiver Assessment Tools (Family Caregiver Alliance)

Examples of caregiver assessment tools used by state agencies.

Assessment Tools

Zarit Burden Interview

Widely used assessment tool. 22- or 12-question caregiver burden assessment that can be self-administered or administered by trained staff as an interview.

Assessment Tools

Caregiver Assessment Tools (Center to Advance Palliative Care)

List of six caregiver assessment tools.

Database of

Best Practice Caregiving Database (Benjamin Rose Institute on Aging and Family Caregiver Alliance)

Over 40 evidence-based dementia-focused Caregiver Support interventions, some with extensive implementation support and many that also support caregivers of people with other conditions.

Program Example

Veterans Affairs (VA) Caregiver Support Program 

The VA provides an example of more comprehensive offerings to caregivers through their Program of General Caregiver Support Services and Program of Comprehensive Assistance for Family Caregivers. 

Payment Model 

Guiding an Improved Dementia Experience (GUIDE) Model

Medicare dementia-focused care model that includes care coordination and care management, caregiver education and support, and respite services. 


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