Foundational Skills for Care Managers
This Learning Pathway contains a comprehensive set of training and tools to help care managers address the unique needs of patients and families living with serious illness. 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
How to initiate and conduct conversations about advance care planning.
Strategies for eliciting patient goals and preferences to inform treatment decisions.
Defines unconscious bias and how it influences patient care, and provides ways to reduce the impact of unconscious bias on care delivery.
Conversation framework and key phrases to share empathy and deepen your relationship with your patient. Vital Talk, 2019.
Phrases to use when talking to members/patients and their families about prognosis, advance planning, and quality of life.
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’.
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