Case Managers: Addressing the Unique Needs of Patients with Serious IllnessLast 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
Starter Set of Online Courses
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 ServicesLast Updated: January 15, 2015
Defining palliative care, which patients need it, how it is delivered, and how palliative care differs from hospice.start the course
Course 1: Comprehensive Pain AssessmentLast Updated: January 15, 2015
Conducting a comprehensive pain assessment to guide safe and effective treatment.start the course
Advance Care Planning ConversationsLast Updated: November 12, 2015
How to initiate and conduct conversations about advance care planning.start the course
Clarifying Goals of CareLast Updated: January 15, 2015
Strategies for eliciting patient goals and preferences to inform treatment decisions.start the course
Health Plan Medical Directors: Supporting Best Care for Members with Serious IllnessLast Updated: October 19, 2017
Guidance for collaborating with treating providers to ensure that members who would benefit receive palliative care.start the course
Care Management for Seriously Ill Patients: Addressing Gaps in CareLast Updated: September 1, 2017
Communication and assessment techniques for case managers to elicit goals of care and address suffering for people with serious illness.start the course
Supporting the Family Caregiver: The Burden of Serious IllnessLast Updated: March 10, 2016
Assessing and supporting caregivers of people with serious illness.start the course
The Human Connection of Palliative Care: 10 Steps for What to Say and DoLast Updated: February 3, 2019
Ten important steps for improving communication between clinicians and patients/families. NOTE: This video does not provide CE credits.view
Resources for Case Managers
Recommended assessment tools and palliative care interventions for case managers.
Patient Identification and AssessmentLast Updated: March 4, 2019
Toolkit for finding the right patients at the right time to address gaps in care.view
Communication Phrases in Palliative CareLast Updated: January 29, 2019
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.members login
Patient Engagement ToolkitLast 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.members login
Online Training Courses for All CliniciansLast 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.view
Resources for Pediatric Case Managers
Use the “Field Guide” to improve support for pediatric patients with serious illness and their families.
Courageous Parents NetworkLast Updated: February 3, 2019
Empowering parents and families of children living with serious illness.view
Pediatric Palliative Care Field GuideLast Updated: February 3, 2019
Catalog of resources, tools and training to promote pediatric palliative care innovation and growth.download
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.
The Secret to Successful Complex Case ManagementLast Updated: February 3, 2019
One-pager on case management approaches for optimizing quality of life for patients with serious illness and their families.download
Case Management for Health Plans and ACOs: Guidance for Engaging and Assessing Patients and Their FamiliesLast Updated: February 28, 2019
Best practices in case manager hiring and training, key processes and assessments, and practical guidance for getting started.download
Population Stratification ConsiderationsLast Updated: February 3, 2019
Guidance on dosing interventions based on patient risk.members login
Case Study: Integrating Palliative Care Into Primary Care Workflows at Mayo ClinicLast Updated: February 3, 2019
Use of palliative care-trained social workers to improve primary care for people living with serious illness.members login
Case Study: Case Manager Training in Action at Integra ACOLast Updated: February 3, 2019
Training complex case managers in communication skills and deprescribing.members login
Mini-Case Study: Patient Assessment Processes at CareMoreLast Updated: February 3, 2019
Using telephonic conversations and in-home visits to fully assess patient and family burdens and needs.members login
Aetna Compassionate Care ProgramLast 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.view