Additional Skills for Care Managers Who Focus Primarily on Supporting People with Serious Illness
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
Defining palliative care, which patients need it, how it is delivered, and how palliative care differs from hospice.
Screening questions and burden assessments for case management of people with serious illness.
Summary of care management strategies for patients living with a serious illness, from preparing for the call to working with treating teams.
Communication and assessment techniques for case managers to elicit goals of care and address suffering for people with serious illness.
Assesses for nine symptoms experienced by patients with serious illness and quantifies their severity. Alberta Health Services.
Brief (4-question) screening tool for anxiety and depression.
Stratifies patients by level of functional ability. Like the PPS, the Karnofsky score can be used to predict survival.
Assessment tool and resource list to address social risk factors.
Short conversation guide to elicit information about a patient's spiritual history and preferences.
Checklist of triggers for referral to a specialty palliative care team.
Strengthen the Clinician-Patient Relationship and Understand Care Goals
Identify the role of physicians and advanced practitioners in introducing patients to ACP.
Build physicians’ and advanced practitioners’ skills in guiding and documenting ACP conversations.
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.
Advice on completing advanced directives and speaking with family and care providers about wishes.
Strategies for eliciting patient goals and preferences to inform treatment decisions.
Definitions, statistics, and strategies to address unconscious bias in health care.
Conversation framework and key phrases to share empathy and deepen your relationship with your patient. Vital Talk, 2019.
Assessing and addressing sources of suffering for people living with chronic obstructive pulmonary disease (COPD), and their caregivers.
Interventions to reduce suffering along the disease trajectory for people living with congestive heart failure (CHF), and their families.
Helping patients and caregivers understand challenges they may face as dementia worsens.
Assessing and supporting caregivers of people with serious illness.
Ten important steps for improving communication between clinicians and patients/families. NOTE: This video does not provide CE credits.
Manage Pain and Symptoms
Conducting a comprehensive pain assessment to guide safe and effective treatment.
Recommended validated cognitive assessment tools.
Prevent Crises and Help Patients 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.
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
This course provides context and best practices for identifying older adults at risk for poor outcomes, including falls, delirium, and caregiving challenges.
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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