New
Safe and Age-Friendly Care 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.
Coordinating Care and Planning Ahead
What You’ll Learn
This course empowers all clinicians - not just care coordinators or specialists - to recognize their role in anticipating gaps in care, communicating effectively, and helping prevent avoidable suffering for patients with serious illness. Even when disease treatment is optimized, patients can still face breakdowns in care. Through real-world examples and actionable strategies, clinicians will learn how to spot vulnerabilities and take simple but powerful steps to ensure coordinated care. Every clinician has a role in coordinating care, planning ahead, and reducing risks for patients with serious illness, and their caregivers.
Learning Outcomes:
- Identify common care gaps and crises experienced by patients with serious illness.
- Define the elements of comprehensive coordinated care for patients with serious illness and their caregivers.
- Describe specific, proactive steps any clinician can take to improve coordination and communication.
- Identify points of vulnerability for patients with serious illness and their caregivers, especially during care transitions.
- Apply strategies to anticipate and prevent crises for patients with serious illness and their caregivers.
What You’ll Earn
Only CAPC members who are logged in can earn the following free Continuing Education Credits:
- 1.00 AMA PRA Category 1 Credit(s)™
- Nursing: 1.00 CNE
- Social Work: 1.00 CE (NYSED)
To take this course, log in. Or, check here to see if your organization is a member.
Login
1
Take the course
2
Take the post-test
3
Complete evaluation
4
Download your certificate
Tools & Resources
Course References: Coordinating Care and Planning Ahead
MEMBERS ONLY
Course citations. Center to Advance Palliative Care, 2025.
Billing and Coding
Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.
Area Agencies on Aging Services Locator
Area Agencies on Aging (AAAs) provide a range of aging services to enable older adults to “age in place” in their homes and communities.
Reducing Care Fragmentation: A Toolkit for Coordinating Care
A publication by the California Health Care Foundation. Includes case studies and guidance for coordinating care in the primary care space.
Case Managment Credentialing Entities and Eligibility Requirements
Guidance from the Case Management Society of America on case management certification options.
The Care Transitions Intervention®
The Care Transitions Intervention® (CTI) is an evidence-based, short-term model that has proven to reduce readmission rates in various populations by activating patient engagement in their health management.
Agency for Healthcare Research and Quality (AHRQ) Care Coordination
Guidance from the AHRQ on measures for coordinated care.
Chronic Care Management Services
Department of Health and Human Services, Centers for Medicare and Medicaid Services.
Accreditations and Disclosures
Physicians
Medical Society of the State of New York
This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Medical Society of the State of New York (MSSNY) and Center to Advance Palliative Care (CAPC). MSSNY is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
As an ACCME-accredited provider, MSSNY is required to identify and mitigate relevant financial relationships of all individuals in control of CME content.
Financial relationships are relevant if the following three conditions are met for the prospective person who will control content of the education:
✓ A financial relationship, in any amount, exists between the person in control of content and an ineligible company.
✓ The financial relationship existed during the past 24 months.
✓ The content of the education is related to the products of an ineligible company with whom the person has a financial relationship.
Allison Applebaum, PH.D., FAPOS, Speaker/Faculty for CAPC National Seminar 2025, has disclosed that she is currently a consultant for Roon. Additionally, Dr. Applebaum was a consultant for Beigene in the last 24 months; however the financial relationship has ended.
None of the other individuals in control of content have relevant financial relationships to disclose.
All relevant financial relationships have been mitigated.
Released: 9/25/2025; Valid for credit through 9/25/2027
Estimated Time of Completion: 60 Minutes
Physician Assistants
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME. The Medical Society of the State of New York designates this enduring material with 1.0 AMA PRA Category 1 Credit™ as specified, which can be applied to the continuing education of Physician Assistants. Physician Assistants should claim only the credit commensurate with the extent of their participation in the activity.
Connecticut Nurses' Association
This nursing continuing professional development activity was approved by Connecticut Nurses’ Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Minutes: 60 minutes or 1.0 contact hours
Valid from: 9/25/2025 through 9/25/2027
Social Workers
Center to Advance Palliative Care SW CPE #0257 is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers effective 9/25/2025 - 7/31/2027. This program has been approved for 1.0 continuing education contact hours.
Certified Case Managers
This program is approved by The Commission for Case Manager Certification (Approval # TBD) to provide 1.0 continuing education credits to CCM® board certified case managers.
Released: 9/25/2025; Valid for credit through 9/25/2026.
Verification of Attendance (VOA)
All users that are not eligible for continuing education will receive a Verification of Attendance certificate upon completion of the course.
Course Media Instructions and Additional Information
Software Requirements: CAPC’s online curriculum, tools and technical assistance are designed to be fully compatible through multiple platforms: computer, smartphone (iOS or Android) or tablet running the following web browsers: Google Chrome, Mozilla Firefox, Safari, and Microsoft Edge.
Content: Each course is comprised of interactive learning components (articles, tools, or supporting materials), video and audio. The learner will be expected to complete various interactive processes such as matching, simulated clinical decision-making, fill in the blanks, and highlighting content.
Target Audience: Each program is developed for chaplains/spiritual counselors, nurses, physicians, physician assistants, social workers, case managers, palliative care program leaders, and healthcare leaders (hospital, health system and community care).
How to Achieve Contact Hours: To successfully earn credit, participants must complete the entire course, receive a minimum score of 80% on the post-test (within 3 attempts), and complete the course evaluation. A printable certificate of completion or a continuing award document specific to the discipline will be awarded. If the participant does not successfully score an 80% or better within 3 attempts they must re-take the course from beginning to end.
Activity Description/Statement of Needs: CAPC’s online curriculum provides training in two critical areas. Technical assistance courses are designed to help palliative care program leaders address key challenges such as implementing palliative care in community health care settings. Clinical coursework provides fundamental training in pain and symptom management, communication, and other key skills needed to work with patients with serious illness.
Faculty Disclosures and Financial Relationships: It is the policy of CAPC to ensure objectivity, balance, independence, transparency, and scientific rigor in all CE, CNE and CME educational activities per the highest standards of ANCC and ACGME guidelines. For all courses, Faculty/Presenters/Authors/Content Reviewers/Planning Committee Members complete forms to disclose their relevant financial relationships. No relevant financial relationships were identified for any individuals with the ability to control content of the activity.
Disclaimers: The opinions expressed in the courses are those of the authors and do not necessarily represent the views of the sponsor, the educational partner, or the supporter. Please review complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.
Activities do not contain information on commercial products/devices that are unlabeled for use or investigational uses of products not yet approved.
Copyright Information: All rights reserved by the Center to Advance Palliative Care (CAPC). No materials may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in articles or reviews.
Course Faculty
Constance Dahlin MSN, ANP-BC, ACHPN, FPCN, FAAN.
Consultant to CAPC
Nurse Planner, Center to Advance Palliative Care
Allison Applebaum, PhD, FAPOS.
Director, Steven S. Elbaum Family Center for Caregiving
Evan Zazula, DMin, MAPCC.
Consultant to CAPC
Palliative Care Chaplain
Brittany Chambers, MPH, MCHES.
Director, Health Equity and Special Initiatives, Center to Advance Palliative Care
Kesha Graham, LISW-CP, ACM-SW.
Consultant to CAPC
Social Work Content Expert
Brynn Bowman, MPA.
Chief Executive Officer, Center to Advance Palliative Care
Assistant Professor, Brookdale Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
Natalie Sohn, MD.
Geriatrics Fellow
Mount Sinai's Geriatric Leadership Program
Rima Itani Al-Nimr, MS, RD, LD.
Director, Clinical Education, Center to Advance Palliative Care
Joyce Rivers-Miller, LMSW, ACM-SW.
Lead Medical Social Worker
Medical University of South Carolina
Peer Reviewers
Sherika Newman, DO.
CAPC Peer Reviewer
Founder, Doctor in the Family, Atlanta, GA
Course Artists
Martha/Bernard illustrated by Bishakh Som
Contact information: For answers to frequently asked questions about CAPC courses and CEs, read the Online Course FAQ. For all other questions, please contact support.
New
Supporting the Caregivers of People with Serious Illness
This course offers tools and guidance for assessing and addressing the needs of caregivers of people with serious illness.