Promoting Excellence : Intake Forms: Pathways of Caring Program

Department of Veteran's Affairs, West Los Angeles Medical Center - Pathways of Caring Program: Intake Forms

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.

Organizational Tools - Enrollment Criteria/Patient Identification

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

M. Jillisa Steckart, Psy.D.
[email protected]

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.

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.

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 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 was 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 for more resources.

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