Name:
Department of Veteran's Affairs, West Los Angeles Medical Center
- Pathways of Caring Program: Intake Forms
Description:
A Screening Form, and Patient Enrollment Checklist used to identify patients
suffering from lung cancer who were appropriate for palliative care services.
Similar forms were developed specifically for chronic heart failure and chronic
obstructive pulmonary disease.
Category:
Organizational Tools - Enrollment Criteria/Patient Identification
Source:
Veterans Affairs - The Greater Los Angeles Healthcare System
Veterans Integrated Palliative (VIP) Program
11301 Wilshire Boulevard, 111-G
Los Angeles, CA 90073
Phone: (310) 268 - 3500
Fax: (310) 268 - 4272
Contact:
M. Jillisa Steckart, Psy.D.
Jillisa.Steckart@med.va.gov
How the grantee used this instrument:
These forms were used at the time of intake of patient and were used in follow
through from the care team.
Keywords:
appropriate patients, identifying patients, patient criteria, patient enrollment,
patient screening, patient selection, lung cancer, COPD, Chronic Obstructive
Pulmonary Disease, CHF, Congestive Heart Failure
To use this tool:
You may print and copy this tool for your own use from this site. Please credit
source.
References:
Developed specifically for this project by the project team.
To view this tool:
Left click on the download link to view the PDF document in your Web browser.
Right-click on the download link to save the document to your computer.
PDF 81 KB / 6 pages (Viewing
PDF files requires downloading and installation of the free Adobe
Acrobat Reader.)
Posted October 2004
Department of Veteran's Affairs, West Los Angeles Medical Center overview page
# VA-WLA13, type:enrollment_criteria
Promoting Excellence in End-of-Life Care is a national program of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families. Visit PromotingExcellence.org for more resources.
