Case Managers: Addressing the Unique Needs of Patients with Serious Illness
The secret to improving outcomes for people living with serious illness is case managers trained to focus on the unique needs of this patient population. Successful case 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 case 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
Starter Set of Online Courses
Seven online CE courses that provide training for case managers working with people with serious illness.
Defining palliative care, which patients need it, how it is delivered, and how palliative care differs from hospice.
Strategies for eliciting patient goals and preferences to inform treatment decisions.
Conducting a comprehensive pain assessment to guide safe and effective treatment.
How to initiate and conduct conversations about advance care planning.
Guidance for collaborating with treating providers to ensure that members who would benefit receive palliative care.
Communication and assessment techniques for case managers to elicit goals of care and address suffering for people with serious illness.
Assessing and supporting caregivers of people with serious illness.
Building Physician Skills in Basic Advance Care Planning, includes three courses intended to build person-centered advance care planning (ACP) skills for physicians and advanced practitioners.
Ten important steps for improving communication between clinicians and patients/families. NOTE: This video does not provide CE credits.
Resources for Case Managers
Recommended assessment tools and palliative care interventions for case managers.
Screening questions and burden assessments for case management of people with serious illness.
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.
Guidance on finding and enrolling patients, and working with treating providers. Updated, November 2019.
Good, better, and best practices for case management and utilization management.
Online training curriculum for all specialties and disciplines to strengthen their care of patients living with serious illness. Free continuing education credits for all, and physicians receive ABIM MOC points for select courses.
Stepwise conversation protocol to assess a patient’s understanding of their illness, elicit patient goals, and share information. Created by Ariadne Labs.
Summary of care management strategies for patients living with a serious illness, from preparing for the call to working with treating teams.
Resources for Pediatric Case Managers
Use the “Field Guide” to improve support for pediatric patients with serious illness and their families.
Empowering parents and families of children living with serious illness.
Catalog of resources, tools and training to promote pediatric palliative care innovation and growth.
Resources for Case Management Leaders
Case 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 case-management programs.
One-pager on case management approaches for optimizing quality of life for patients with serious illness and their families.
Best practices in case manager hiring and training, key processes and assessments, and practical guidance for getting started.
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.
Guidance on dosing interventions based on patient risk.
Use of palliative care-trained social workers to improve primary care for people living with serious illness. CAPC and the Accountable Care Learning Collaborative.
Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.
Using telephonic conversations and in-home visits to fully assess patient and family burdens and needs.