The secret to improving outcomes for people living with serious illness is care managers trained to focus on the unique needs of this patient population. Successful care managers—across all types of settings, in health plans, and in other types of organizations—use specific communication and assessment skills. Built on motivational interviewing, these skills focus on eliciting patient hopes and fears in the context of their illness and uncovering distress and unmet needs.

This toolkit provides online courses and resources for care managers to meet the needs of patients with serious illness.

Download a course catalog with information about continuing education credits for all CAPC courses here.

What’s in the Toolkit

This Learning Pathway contains a comprehensive set of training and tools to help care managers address the unique needs of patients and families living with serious illness.

Foundational Skills for Care Managers

This Learning Pathway contains a comprehensive set of training and tools to help care managers address the unique needs of patients and families living with serious illness.

Best Practices in Initial Patient Outreach
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Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.

Best Practices in Initial Patient Outreach - Sample Recording
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Sample recruiter-patient audio exchange.

This Learning Pathway contains a comprehensive set of training and tools to help care managers who focus primarily on supporting people with serious illness address the unique needs of patients and families.

Additional Skills for Care Managers Who Focus Primarily on Supporting People with Serious Illness

This Learning Pathway contains a comprehensive set of training and tools to help care managers address the unique needs of patients and families living with serious illness.

Use the “Field Guide” to improve support for pediatric patients with serious illness, and their families.

Courageous Parents Network

Empowering parents and families of children living with serious illness.

Pediatric Palliative Care Field Guide

Catalog of resources, tools and training to promote pediatric palliative care innovation and growth.

Care managers already engage with the population of people living with serious illness, but often miss the opportunity to have goal-setting conversations or intercede to reduce suffering. This toolkit provides guidance on integrating palliative care principles and practices into existing care-management programs.

The Secret to Successful Complex Case Management

One-pager on case management approaches for optimizing quality of life for patients with serious illness and their families.

Case Management for Health Plans and ACOs: Guidance for Engaging and Assessing Patients and Their Families

Best practices in case manager hiring and training, key processes and assessments, and practical guidance for getting started.

Aetna Compassionate Care Program

The pioneering example of using palliative care principles in health plan case management. The program resulted in both high member satisfaction rates and cost savings.

Population Stratification Considerations
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Guidance on dosing interventions based on patient risk.

Case Study: Integrating Palliative Care Into Primary Care Workflows at Mayo Clinic
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Use of palliative care-trained social workers to improve primary care for people living with serious illness. CAPC and the Accountable Care Learning Collaborative.

Case Study: Case Manager Training in Action at Integra ACO
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Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.

Mini-Case Study: Patient Assessment Processes at CareMore
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Using telephonic conversations and in-home visits to fully assess patient and family burdens and needs.