Serious Illness (formerly Palliative Care) - Optimizing Serious Illness Conversations, Conducting a Comprehensive Assessment and Care Coordination

Purpose of the Serious Illness Training 

• The SI training provides clinicians with the foundational knowledge, skills and confidence to engage in serious illness conversations with individuals who have a life limiting condition. The purpose of the SI conversation is to elicit an individual’s goals, values and preferences for care and once known, facilitate a plan of care that aligns with those stated values, goals and preferences. 
• Research has demonstrated that engaging in Serious Illness conversations can improve patient and family satisfaction, reduce provider burnout and reduce non-clinically beneficial services. Implications for Case Management Practice: 
• Case managers often lack the formal or informal education about engaging in conversations with patients living with an SI(s), regarding their goals of care and advanced care planning. They may be limited exposure to the latest generation of screening tools that assess the cultural context of patient and caregiver psychosocial needs encompassing behavioral health symptoms and conditions, caregiver burden, cultural competence, health-related social needs, Techquity, and digital health literacy. Such education is essential to attaining successful patient outcomes, particularly as SI conversations are within the case managers’ role and responsibility. 
• Establishing a protocol for case managers to follow is essential, including identifying patients appropriate for an SI conversation, conducting an SI conversation, and documenting information from the SI conversation in the electronic medical record. 
• Conducting SI conversations with appropriately identified patients and their caregivers is expected to result in the establishment of a plan of care consistent with patient preferences. 

Who should attend this training? 

Provider Delivered Care Managers (PDCM) for adult, family, and pediatric clinics will benefit from this training. Individuals, guardians and parents who have or who are the decision-makers for complex conditions such as rare disorders, advanced chronic conditions, severe mental illness, and dementia will benefit from providers developing confidence and engaging in serious illness conversations with them. 

The goal is to ensure there is clear understanding of the patient’s/families wishes in advance of a crisis situation. Empowering team members with these evidence-based skills and considerations, positions care teams to understand and advocate the patient/family wishes should their condition advance to a point where the patient cannot effectively communicate their wishes.