Care Managers: Addressing the Unique Needs of Patients with Serious Illness
The secret to improving outcomes for people living with serious illness is care managers trained to focus on the unique needs of this patient population. Successful care managers—across all types of settings, in health plans, and in other types of organizations—use specific communication and assessment skills. Built on motivational interviewing, these skills focus on eliciting patient hopes and fears in the context of their illness and uncovering distress and unmet needs.
This toolkit provides online courses and resources for care managers to meet the needs of patients with serious illness.
Download a course catalog with information about continuing education credits for all CAPC courses here.
What’s in the Toolkit
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.
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.
Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.
Sample recruiter-patient audio exchange.
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.
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.
This script for care managers provides guidance and sample language to use when calling without a prior relationship to begin care planning for patients with serious illness.
Resources for Pediatric Care Managers
Use the “Field Guide” to improve support for pediatric patients with serious illness, and their families.
Empowering parents and families of children living with serious illness.
Catalog of resources, tools and training to promote pediatric palliative care innovation and growth.
Resources for Care Management Leaders
Care managers already engage with the population of people living with serious illness, but often miss the opportunity to have goal-setting conversations or intercede to reduce suffering. This toolkit provides guidance on integrating palliative care principles and practices into existing care-management programs.
One-pager on case management approaches for optimizing quality of life for patients with serious illness and their families.
Best practices in case manager hiring and training, key processes and assessments, and practical guidance for getting started.
Screening questions and burden assessments for case management of people with serious illness.
Advice from successful programs on how to make "cold calls" to patients identified to benefit from your services.
Sample recruiter-patient audio exchange.
The pioneering example of using palliative care principles in health plan case management. The program resulted in both high member satisfaction rates and cost savings.
Guidance on dosing interventions allocating visit frequency based on patient risk.
