This Learning Pathway contains a comprehensive set of training and tools to help advanced practice providers who focus primarily on supporting people with serious illness address the unique needs of patients and families. Clinical topics include assessing patient needs and concerns, understanding patients’ goals for care, addressing symptom burden, and helping patients to avoid crises and plan for the future.

Assess the Needs and Concerns of Patients

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.

Revised Edmonton Symptom Assessment System (ESAS-r)

Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.

PHQ-4 Validated Screening Tool for Anxiety and Depression

Brief (4-question) screening tool for anxiety and depression.

Social Needs Screen

Assessment tool and resource list to address social risk factors.

FICA Spiritual Assessment Tool

Short conversation guide to elicit information about a patient's spiritual history and preferences.

Zarit Burden Interview (ZBI-12)

Self-reported caregiver assessment.

CAPC Palliative Care Referral Criteria

Checklist of triggers for referral to a specialty palliative care team.

Strengthen the Clinician-Patient Relationship and Understand Care Goals

Basic Advance Care Planning: Introduce and Motivate

Identify the role of physicians and advanced practitioners in introducing patients to ACP.

Basic Advance Care Planning: Guide and Document

Build physicians’ and advanced practitioners’ skills in guiding and documenting ACP conversations.

Billing and Coding for Advance Care Planning (ACP) Services
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Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.

Clarifying Goals of Care

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

Delivering Serious News

Communicating serious clinical news to patients and families.

Discussing Prognosis

How to discuss patient prognosis in a manner that is sensitive, clear, and supportive.

Unconscious Bias: What It Is, How It Influences Health Care, and What You Can Do About It

Defines unconscious bias and how it influences patient care, and provides ways to reduce the impact of unconscious bias on care delivery.

Talking with Patients About Hospice

This resource lists step-wise tips to foster comfortable, productive dialogue for ‘the hospice conversation’.

Manage Pain and Symptoms

Course 3: Patient Factors that Influence Prescribing Decisions

Patient and family factors that influence prescribing decisions for patients with serious illness.

Course 5: Opioid Trials: Determining Design, Efficacy, and Safety

Designing a safe and effective opioid trial for the patient with serious illness.

Course 6: Prescribing An Opioid

Safe and appropriate opioid prescribing for the opioid-naive patient with serious illness.

Course 8: Monitoring for Opioid Efficacy, Side Effects, and Substance Use Disorder

Ongoing evaluation of opioid benefits, risks, and side effects for the patient with serious illness.

Dyspnea in Patients with Serious Illness

Take this online course to learn how to manage dyspnea, including the physical causes of shortness of breath and the emotional impact on the patient.

Nausea and Vomiting in Patients with Serious Illness

Nausea and vomiting are common symptoms of serious illness, and can cause dangerous complications. Take this online course to learn practical skills to identify, manage, and reduce these symptoms.

Constipation in Patients with Serious Illness

Constipation occurs in at least 70% of patients living with a serious illness and often goes unrecognized. Take this online course to learn critical skills to identify and manage the impact of constipation.

Anxiety in Patients with Serious Illness

Take this online course to learn evidence-based strategies to identify and treat anxiety in patients with a serious illness.

Depression in Patients with Serious Illness

This online course teaches how to accurately identify and treat depression in patients living with a serious illness.

Cognitive Assessment Tools

Recommended validated cognitive assessment tools.

Prevent Crises and Help Patients Plan Ahead

Supporting Patients with Serious Illness to Plan Ahead

Considerations for clinicians, patients, and families upon diagnosis, including advance care planning, personal care needs, legal and financial planning, work and retirement planning, and prevention of common medical risks.

Reducing Risks for Older Adults

This course provides context and best practices for identifying older adults at risk for poor outcomes, including falls, delirium, and caregiving challenges.

ePrognosis

Geriatric prognosis calculator based on a systematic review of prognostic indices, with links to disease-specific prognosis tool when applicable. Includes communication tools for talking with patients about prognosis, and can be used on a mobile phone or tablet. Created and maintained by the University of San Francisco.

FindHelp.org

National database of community services - enter a zip code and locate assistance with food, housing, health services, care needs, and other resources.

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