Clinical Training Recommendations for Clinical Care Managers Caring for Patients with Serious Illness

These training recommendations will help clinical care managers address the unique needs of patients living with serious illness.

Assess the Needs and Concerns of Patients

• Know what palliative care is, and how it benefits patients/members
• Recognize common sources of suffering for people living with serious illness
• Perform a comprehensive assessment of the needs and concerns of patients using open-ended questions, including the following:
  • Pain and other physical symptom distress
  • Psychological symptom distress, including depression and anxiety
  • Polypharmacy and anticholinergic burden
  • Functional impairment
  • Caregiver burden
  • Social risk factors
  • Communication needs
• Assess for need for adaptive equipment

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Identify the patient’s surrogate decision-maker
• Identify how culture, race, gender, sexual orientation, and context (e.g., social determinants of health) influence patient and family decision-making in the context of a serious illness, and deliver culturally-responsive care and services
• Advocate for care that is aligned with patients’ values and preferences

Manage Pain and Symptoms

• Initiate steps for symptom management when patient is in distress
• (If in the context of a health plan or long-term patient engagement) Perform ongoing monitoring and assessment of symptom control
• Assess the feasibility and safety of the care plan (e.g., whether prescribed medications are accessible and affordable) and alert the care team to any risks

Prevent Crises and Plan Ahead

• Recommend additional supports and make linkages, based on assessment findings and patient’s insurance/available benefits; these supports may include:
  • Benefits and entitlements assistance
  • Personal care assistance
  • Meal assistance
  • Home safety assessment and DME need
  • Adaptive equipment
  • Caregiver/family support services
  • Caregiver respite services
  • Behavioral health services
• (If participating in discharge planning) Educate patient on follow-up appointments
• Discuss potential hospice eligibility with the primary team

Complete the Learning Pathway, Foundational Skills for All Clinical Care Managers, to acquire these skills.

Assess the Needs and Concerns of Patients

• Determine patient/member’s level of knowledge about their illness
• Listen actively for emotional and spiritual distress; invite dialog on these issues

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Explain what to expect about their illness
• Elicit information from patients about what matters most to them now that they have a diagnosis of a serious illness
• Conduct advance care planning conversations and complete advance directives
• Provide tools and referrals to assist with family communication and decision-making

Manage Pain and Symptoms

• Identify patients in need of specialty palliative care consultation, educate patient and family on palliative care, and take steps to initiate a consult

Prevent Crises and Plan Ahead

• Map the resources and service providers in the community that can support patients with serious illness
• Identify patients who may be at high risk for exacerbations, and link to 24/7 supportive services, such as home-based care programs
• Identify barriers to meeting patient and family needs and honoring their priorities, and discuss the least restrictive alternatives (e.g., home redesign or board and care home versus nursing home placement)
• Recommend spiritual supports, and make linkages as appropriate

Complete the Learning Pathway, Additional Skills for Clinical Care Managers who Focus Primarily on Supporting People with Serious Illness, to acquire these skills.

Thank you to the following clinicians for their review of these recommendations: Ali Bengs, MSc, BS, RN; Allison Silvers, MBA; Brittany Wilson, BSN, RN