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
Introduction to Palliative Care
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
MEMBERS ONLY
Summary of care management strategies for members 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
MEMBERS ONLY
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.
Care Planning
Learn techniques to help patients and their caregivers plan for the future, both during the early stages of a serious illness and as a disease progresses.
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.
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.
Manage Pain and Symptoms
Course 1: Pain and its Impact on Our Patients
Learn to define and characterize pain, recognize the prevalence of pain, understand disparities in pain management based on race, ethnicity, and gender.
Course 2: How to Perform a Comprehensive Pain Assessment
Learn the components of a comprehensive pain assessment and its importance in safe and effective pain management.
Course 3: Matching Treatment to Pain Type
Gain an overview of pharmacologic and nonpharmacologic pain treatments, including risks and benefits, and learn how to match the analgesic to pain type.
Course 8: Problems with Opioid Prescribing: Is it an Opioid Use Disorder?
Learn how to identify and diagnose opioid use disorder (OUD) and practice communicating with patients about OUD and pain management.
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.
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’.
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