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. 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

Introduction to Palliative Care for Health Professionals

An introduction to palliative care, how it is delivered, its impact on quality of life, and the growing population of patients who need it.

Screening and Assessment for Key Gaps in Care

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

Best Practices in Telephonic Care Management

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

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.

Karnofsky Performance Status Scale Definitions Rating (%) Criteria

Stratifies patients by level of functional ability. Like the PPS, the Karnofsky score can be used to predict survival.

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.

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

Clarifying Patient Goals of Care

Learn best practices for building trust, eliciting patient values, and having patient-centered conversations about goals of care.

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.

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.

American Bar Association ACP Toolkit

Advice on completing advanced directives and speaking with family and care providers about wishes.

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.

Responding to Emotion: Vital Talk Quick Guide for Conversations

Conversation framework and key phrases to share empathy and deepen your relationship with your patient. Vital Talk, 2019.

Supporting the Family Caregiver: The Burden of Serious Illness

Assessing and supporting caregivers of people with serious illness.

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.

Manage Pain and Symptoms

Course 1: Comprehensive Pain Assessment

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

Cognitive Assessment Tools

Recommended validated cognitive assessment tools.

Managing Mood and Sleep Disturbances in People Living With Dementia

Learn how to relieve suffering from common mood and sleep disturbances in order to improve quality of life for people living with dementia, and caregivers.

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.

Psychosocial Assessment for Patients with Serious Illness

Assessment questions to help nurses understand the impact of serious illness on a patient's relationships, social and spiritual supports, financial stability, and trust in the health care system. Fast Facts, April 2020

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.

Talking with Patients About Hospice

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

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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Age-Friendly Health Care

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