Office of Palliative Care

ACGME Milestones

The film, No Roadmap: Caregiver Journeys, coupled with case discussions and clinical encounters in hospital, clinic and home settings, encompasses multiple reporting milestones for medical and surgical residents. Additionally, we have developed an assessment tool which links resident interactions with caregivers to discipline-specific milestones. The assessment tool can be useful to faculty in documenting the resident’s level of milestone achievement.

Patient Care – 2
  • Appropriately modifies care plans based on patient’s clinical course, additional data and patient preferences.  (Level 4)
  • Develops customized, prioritized care plans for the most complex patients, incorporating diagnostic uncertainty and cost effectiveness principles.  (Level 5)
System-Based Practice – 1
  • Understands the roles and responsibilities of and effectively partners with all members of the team.  (Level 4)
  • Actively engages in team meetings and collaborative decision-making.  (level 4)
  • Integrates all members of the team into the care of patients, such that each is able to maximize their skills in the care of the patient.  (Level 5)
System Based Practice – 4
  • Appropriately utilizes available resources to coordinate care and ensures safe and effective patient care within and across delivery systems.  (Level 4)
  • Proactively communicates with past and future care givers to ensure continuity of care.  (Level 4)
  • Coordinates care within and across health delivery systems to optimize patient safety, increase efficiency and ensure high quality patient outcomes.  (Level 5)
  • Anticipates needs of patients, caregivers and future care providers and takes appropriate steps to address those needs.  (Level 5)
  • Role models and teaches effective transitions of care.  (Level 5)
Professionalism – 1
  • Demonstrates empathy, compassion and respect to patients and caregivers in all situations.  (Level 4)
  • Anticipates, advocates for, and proactively works to meet the needs of patients and caregivers.  (Level 4)
  • Positively acknowledges input of members of the interprofessional team and incorporates that input into plan of care as appropriate.  (Level 4)
  • Role models compassion and respect for patients and caregivers.  (Level 5)
  • Role models appropriate anticipation and advocacy for patient and caregivers.  (Level 5)
  • Fosters collegiality that promotes a high-functioning interprofessional team.  (Level 5)
Professionalism – 3
  • Recognizes and accounts for the unique characteristics and needs of the patient/caregiver.  (Level 4)
  • Appropriately modifies care plan to account for a patient’s unique characteristics and needs.  (Level 4)
  • Role models professional interactions to negotiate differences related to a patient’s unique characteristics or needs.  (Level 5)
Interpersonal and Communication Skills – 1
  • Identifies and incorporates patient preferences in shared decision-making across a wide variety of patient care conversations.  (Level 4)
  • Quickly establishes a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds.  (Level 4)
  • Role models effective communication and development of therapeutic relationships in both routine and challenging situations.  (Level 5)
  • Models cross-cultural communication and establishes therapeutic relationships with persons of diverse socioeconomic backgrounds.  (Level 5)
Interpersonal and Communication Skills – 2
  • Consistently and actively engages in collaborative communication with all members of the team.  (Level 4)
  • Verbal, non-verbal and written communication consistently acts to facilitate collaboration with the team to enhance patient care.  (Level 4)
  • Role models and teaches collaborative communication with the team to enhance patient care, even in challenging settings and with conflicting team member opinions.  (Level 5)
Patient Care – 2
  • Clarifies the goals of care for the patient across the course of the chronic condition and for his or her family and community.  (Level 3)
  • Leads teams to consistently and appropriately manage patients with chronic conditions and co-morbidities.  (Level 4)
  • Facilitates patients’ and families’ efforts at self-management of their chronic conditions, including use of community resources and services.  (Level 4)
  • Personalizes the care of complex patients with multiple chronic conditions and co-morbidities to help meet the patient’s goals of care.  (Level 5)
Medical Knowledge – 2
  • Recognizes the effect of an individual’s condition on families and the population.  (Level 3)
  • Integrates in-depth medical and personal knowledge of patient, family and community to decide, develop, and implement treatment plans.  (Level 5)
System Based Practice – 1
  • Knows and considers costs and risks/benefits of different treatment options in common situations.  (Level 2)
  • Coordinates individual patient care in a way that is sensitive to resource use, efficiency, and effectiveness.  (Level 3)
  • Partners with patients to consistently use resources efficiently and cost effectively in even the most complex and challenging cases.  (Level 4)
  • Role models and promotes efficient and cost-effective use of resources in the care of patients in all settings.  (Level 5)
System Based Practice – 4
  • Engages the appropriate care team to provide accountable, team-based, coordinated care centered on the individual patient needs.  (Level 3)
  • Assumes responsibility for seamless transitions of care.  (Level 3)
  • Sustains a relationship as a personal physician to his/her own patients.  (Level 3)
  • Accepts responsibility for the coordination of care, and directs appropriate teams to optimize the health of patients.  (Level 4)
  • Role models leadership, integration, and optimization of care teams to provide quality, individualized patient care.  (Level 5)
Professionalism – 3
  • Anticipates and develops a shared understanding of needs and desires with patients and families; work in partnership to meet those needs.  (Level 4)
  • Demonstrates leadership in cultural proficiency understanding of health disparities, and social determination of health.  (Level 5)
  • Develops organizational policies and education to support the application of these principles in the practice of medicine.  (Level 5)
Communication – 1
  • Connects with patients and families in a continuous manner that fosters trust, respect, and understanding, including, the ability to manage conflict.  (Level 4)
  • Role models effective, continuous, personal relationships that optimize the well-being of the patient and family.  (Level 5)
Communication – 2
  • Educates and counsels patients and families in disease management and health promotion skills.  (Level 4)
  • Effectively communicates difficult information, such as end-of-life discussions, delivery of bad news, acknowledgement of errors, and during episodes of crisis.  (Level 4)
  • Maintains a focus on patient-centeredness and integrates all aspects of patient care to meet patients’ needs.  (Level 4)
  • Role models effective communication with patients, families and the public.  (Level 5)
Communication – 3
  • Effectively uses electronic record to exchange information among health care team.  (Level 3)
  • Communicates collaboratively with health care team by listening attentively, sharing information and giving and receiving constructive feedback.  (Level 3)
  • Sustains collaborative working relationships during complex and challenging situations, including transitions of care.  (Level 4)
  • Effectively negotiates and manages conflict among members of the health team in the best interest of the patients.  (Level 4)
  • Role models effective collaboration with other providers that emphasizes efficient patient-centered care.  (Level 5)
Communication – 4
  • Ensures transitions of care are accurately documented, and optimizes communication across systems and continuums of care.  (Level 3)
  • Uses technology to optimize continuity care of patients and transitions of care.  (Level 4)
  • Stays current with technology and adapts systems to improve communication with patients, providers and systems.  (Level 5)
System Based Practice – 1
  • The resident is able to efficiently arrange disposition planning for his/her patients and takes responsibility for preparing all materials necessary for discharge or transfer of his/her patients.  (Level 3)
  • This resident coordinates the activities of residents, nurses, social workers, and other healthcare professionals to provide optimal care to the patient at the time of discharge or transfer, and to provide post-discharge ambulatory care that is appropriate for the patient’s particular needs.  (Level 4)
Professionalism – 1
  • The resident ensures patient care responsibilities are performed and continuity of care is maintained.  (Level 3)
Interpersonal Communication Skills – 1
  • The resident is capable of delivering bad news to patients and their families sensitively and effectively.  (Level 3)
  • The resident can customize emotionally difficult information (e.g. when participating in end-of-life care discussions.  (Level 4)
Interpersonal Communication Skills – 2
  • The resident discusses care plans with members of the health care team and keeps them up to date on patient strategies and care plan changes. (Level 3)
  • The resident delivers timely, complete, and well organized information to referring physicians and to providers of follow-up care at the time of patient care transitions.  (Level 3)
  • The resident assumes overall leadership of a health care team responsible for his/her patients, while at the same time seeking input from the members of the team.  (Level 4)
  • This resident takes responsibility for ensuring that clear hand-offs are given at transitions of care.  (Level 4)

Compassion, integrity, and respect for others as well as sensitivity and responsiveness to diverse populations, including but not limited to diversity in gender age, culture, race, religion, disabilities, and sexual orientation.  Knowledge about respect for and adherence to the ethical principles relevant to the practice of medicine, remembering in particular that responsiveness to patients supersedes self-interest is an essential aspect of medical practice.

  • Level 1: Communicates with patients about routine care
  • Level 2: Communicates competently within systems and other care providers, and provides detailed information about patient care
  • Level 3: Communicates competently in difficult patient circumstances
  • Level 4: Communicates competently in complex/adversarial situations
  • Level 5: Demonstrates leadership in communication activities
Level 1
  • Recognizes and communicates critical patient information in a timely and accurate manner to other members of the treatment team
  • Recognizes and communicates role as a team member to patients and staff
  • Responds to requests for information


Level 2
  • Supports and respects decisions made by team
  • Actively participates in team-based care; supports activities of other team members, communicates their roll to the patient and family


Level 3
  • Able to facilitate, direct, and delegate team-based patient care activities


Margaret Sanders, M.A., LSW

Kathleen Enoch

Building Caregiver Partnerships

This site contains a free compendium of educational tools and resources on issues of family caregiving for health professions faculty, providers and students.

Co-sponsored with Summa Health and funded by the Arthur Vining Davis Foundations.

Office of Palliative Care

Department of Family & Community Medicine