Resource Guide for Health Care Teams

This guide offers busy health care professionals the tools and resources needed to include family caregivers in a patient’s care journey, helping to improve patient care and enhance the caregiver’s experience.

Why Include Family Caregivers in Health Care Teams?

• Valuable context – caregivers can provide insights about a patient’s daily life, ultimately streamlining the care process.
• Better experience – sharing patient information with caregivers leads to higher patient and caregiver satisfaction.
• Greater satisfaction – when caregivers feel prepared, they are more likely to report less stress and depression and better quality of life for themselves.
• Reduced risk – a caregiver can help coordinate health care teams, which reduces the risk of hospital readmission after an acute illness.

Health Care Provider Tools for Engaging Caregivers

These tools and skills, which are not often emphasized in clinical training, can help health care professionals effectively identify, engage, and support caregivers, ensuring a more comprehensive approach to patient care.

• Access practical training on identifying, engaging, and supporting caregivers with Caregivers As Partners in Care Teams (CAP-CT). CAP-CT trainings are offered as self-paced, online courses with the option to claim free continuing education credits.
• Utilize efficient, effective caregiver assessment tools
  • The CAP-CT’s Caregiver Identification Tool provides simple prompts to identify a patient’s caregiving team and formalize support roles.
  • Accountable Health Communities (AHC) HRSN Tool is a comprehensive tool to assess a patient’s need for caregiving support, safety, access to food, housing, and affordability of utilities.
  • Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) is a social drivers of health screening that is available in 25 languages.
  • Zarit Burden Interview is a short series of questions to gauge caregiver stress.
• Learn about the unique needs of diverse caregivers with the Caring for Those Who Care Toolkit and training program, or Support Caregiving’s Resource Guide for Kinship/Grandfamily Providers. Learn about special concerns of LGBTQ+ caregivers from the Family Caregiver Alliance.

Caregiving Resources for Provider Referrals  

A health care team can effectively connect caregivers to resources. These key national resources, with local referrals, address common caregiver needs:

• Comprehensive Needs (including respite care)
  • Area Agency on Aging, Eldercare Locator connects older adults, and often anyone with a disability, with local resources including support services, legal and financial planning, respite care, etc.
  • Administration for Community Living provides a good starting point for resources for older adults, people with disabilities, and caregivers.
  • Family Caregiver Alliance offers care planning, direct care skills training, wellness programs, respite services, and legal/financial consultation.
  • Caregiver Action Network provides free peer support and resources for managing caregiving tasks, understanding conditions, and finding support communities.
  • USAging works to improve services and resources for older adults, including within Native American communities.
  • ARCH National Respite Center offers the National Respite Locator Service.

• Financial and Legal Planning
  • PREPARE for Your Care helps with medical planning and decisions.
  • Clarity is for anyone who needs help managing finances, especially helpful for people with memory difficulties and their caregivers.
• Food Insecurity
  • U.S. Department of Agriculture finder has a nutrition program for seniors.
  • Meals on Wheels is a delivery service for individuals who are unable to prepare meals for themselves due to age, disability, or health issues.
• Transportation
  • Eldercare Locator helps older adults and their caregivers find local transportation options and guidelines for how to discuss transportation independence.
  • Rides in Sight provides transportation information for older adults in local communities throughout the U.S; information is made available through a website and hotline.
  • National Aging and Disability Transportation Center promotes the availability and accessibility of transportation options that meet the needs of older adults, people with disabilities, and caregivers.
• Accessing the Health Record
  • The Guide to Getting and Using your Health Record-Digital Literacy Resource helps patients and caregivers access and use their health records to support their health and wellbeing.
  • Coalition for Care Partners builds knowledge and tools to help health systems systematically identify, engage, and support care partners in care delivery. Its OpenNotes for Care Partners supports using electronic record notes to help someone else with their health care.
• Emotional Support and Caregiver Education Services
  • Alzheimer’s Association provides support groups and other activities that promote wellbeing for caregivers and those with Alzheimer’s Disease and related dementias.
  • Best Programs for Caregiving is a directory of evidence-based programs for family caregivers of people with dementia that includes information for providers.
  • RUSH Caring for Caregivers (C4C) is a program that has been proven to have positive health-related outcomes for both older adults and their care partners. C4C uses an evidence-based framework to improve care for older adults and caregivers through education, resources and support.
  • CDC’s list of resources provides services for caregivers of individuals with a range of conditions related to the heart and lung, stroke, cancer, and Alzheimer’s Disease and related dementias.
  • For participating sites, CMS’ Guiding an Improved Dementia Experience (GUIDE) Program provides comprehensive dementia care and caregiver supports.
  • Office of Women’s Health provides services focused on women’s wellbeing.

Billing Guides for Care Teams

Financial support is another lever to help health care teams adequately address the comprehensive needs of caregivers.

The CAP-CT Caregiver Training Billing Guides are designed to help health care teams navigate reimbursement for caregiver training and education. The guides include the new billing codes introduced in the 2024 Medicare Physician Fee Schedule, with the goal of enhancing patient care by equipping caregivers with the knowledge and resources they need to support their loved one, while also managing their own health.

These codes can be utilized during routine visits, Initial and Subsequent Annual Wellness Visits, Health Risk Assessments, follow-up visits, and more.