Case Managers: Addressing the Unique Needs of Patients with Serious Illness

Last Reviewed: March 4, 2019

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

Seven online CE courses that provide training for case managers working with people with serious illness.

An In-Depth Look At Palliative Care And Its Services

Last Updated: January 15, 2015

Defining palliative care, which patients need it, how it is delivered, and how palliative care differs from hospice.

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Course 1: Comprehensive Pain Assessment

Last Updated: January 15, 2015

Conducting a comprehensive pain assessment to guide safe and effective treatment.

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Advance Care Planning Conversations

Last Updated: November 12, 2015

How to initiate and conduct conversations about advance care planning.

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Clarifying Goals of Care

Last Updated: January 15, 2015

Strategies for eliciting patient goals and preferences to inform treatment decisions.

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Health Plan Medical Directors: Supporting Best Care for Members with Serious Illness

Last Updated: October 19, 2017

Guidance for collaborating with treating providers to ensure that members who would benefit receive palliative care.

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Care Management for Seriously Ill Patients: Addressing Gaps in Care

Last Updated: September 1, 2017

Communication and assessment techniques for case managers to elicit goals of care and address suffering for people with serious illness.

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Supporting the Family Caregiver: The Burden of Serious Illness

Last Updated: March 10, 2016

Assessing and supporting caregivers of people with serious illness.

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The Human Connection of Palliative Care: 10 Steps for What to Say and Do

Last Updated: February 3, 2019

Ten important steps for improving communication between clinicians and patients/families. NOTE: This video does not provide CE credits.

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Recommended assessment tools and palliative care interventions for case managers.

Patient Identification and Assessment

Last Updated: March 4, 2019

Toolkit for finding the right patients at the right time to address gaps in care.

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Communication Phrases in Palliative Care

Last Updated: January 29, 2019

Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.

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Patient Engagement Toolkit

Last Updated: February 3, 2019

Identifying the population in need of palliative care, and working with patients and treating clinicians for effective relationships. Includes suggested phone scripts.

Online Training Courses for All Clinicians

Last Updated: March 18, 2019

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.

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

Courageous Parents Network

Last Updated: February 3, 2019

Empowering parents and families of children living with serious illness.

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Pediatric Palliative Care Field Guide

Last Updated: February 3, 2019

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

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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.

The Secret to Successful Complex Case Management

Last Updated: February 3, 2019

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

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

Last Updated: February 28, 2019

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

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Population Stratification Considerations

Last Updated: February 3, 2019

Guidance on dosing interventions based on patient risk.

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Case Study: Integrating Palliative Care Into Primary Care Workflows at Mayo Clinic

Last Updated: February 3, 2019

Use of palliative care-trained social workers to improve primary care for people living with serious illness.

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Case Study: Case Manager Training in Action at Integra ACO

Last Updated: February 3, 2019

Training complex case managers in communication skills and deprescribing.

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Mini-Case Study: Patient Assessment Processes at CareMore

Last Updated: February 3, 2019

Using telephonic conversations and in-home visits to fully assess patient and family burdens and needs.

Aetna Compassionate Care Program

Last Updated: February 3, 2019

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.

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