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

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

Clarifying Goals of Care

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

Course 1: Comprehensive Pain Assessment

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

Advance Care Planning Conversations

How to initiate and conduct conversations about advance care planning.

Communicating with Treating Clinicians: How Medical Directors Can Support Best Care for the Seriously Ill

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

Care Management for Seriously Ill Patients: Addressing Gaps in Care

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

Supporting the Family Caregiver: The Burden of Serious Illness

Assessing and supporting caregivers of people with serious illness.

Building Physician Skills in Basic Advance Care Planning

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.

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

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

Recommended assessment tools and palliative care interventions for case managers.

Screening and Assessment for Key Gaps in Care
MEMBERS ONLY locked

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

Communication Phrases in Palliative Care
MEMBERS ONLY locked

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

Patient Identification and Engagement Guide
MEMBERS ONLY locked

Guidance on finding and enrolling patients, and working with treating providers. Updated, November 2019.

Best Practices in Medical Management for Members with Serious Illness
MEMBERS ONLY locked

Good, better, and best practices for case management and utilization management.

Online Clinical Training Courses For All Clinicians

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.

Serious Illness Conversation Guide

Stepwise conversation protocol to assess a patient’s understanding of their illness, elicit patient goals, and share information. Created by Ariadne Labs.

Best Practices in Telephonic Care Management
MEMBERS ONLY locked

Summary of care management strategies for patients living with a serious illness, from preparing for the call to working with treating teams.

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.

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

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
MEMBERS ONLY locked

Guidance on dosing interventions based on patient risk.

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

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
MEMBERS ONLY locked

Training complex case managers in communication skills and deprescribing. CAPC and the Accountable Care Learning Collaborative.

Mini-Case Study: Patient Assessment Processes at CareMore
MEMBERS ONLY locked

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