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
MEMBERS ONLY locked

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
MEMBERS ONLY locked

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.

Sample Script and Guidance: Cold-Calling Patients to Initiate Advance Care Planning
MEMBERS ONLY locked

This script for care managers provides guidance and sample language to use when calling without a prior relationship to begin care planning for patients 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.

Screening and Assessment for Key Gaps in Care

Screening questions and burden assessments for case management of people with serious illness.

Best Practices in Initial Patient Outreach
MEMBERS ONLY locked

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
MEMBERS ONLY locked

Sample recruiter-patient audio exchange.

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
MEMBERS ONLY locked

Guidance on dosing interventions allocating visit frequency based on patient risk.

Improving operations and training clinical staff to identify, stratify, and meet the needs of patients living with serious illness at the population level. Includes 24 resources.
Tools to make the case for palliative care resources and financial partnerships, including the palliative care evidence base and downloadable tools for presenting the case. Includes 27 resources.
Tools to design and implement a training initiative for care teams from all specialties, to improve quality of life for patients and families living with serious illness. Includes 27 resources.

See all 47 Toolkits

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