In its September 2014 report, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life," the Institute of Medicine recommends the development of measurable, actionable, and evidence-based quality standards for clinician-patient communication and advance care planning to reflect the evolving population and health system needs.

Poor prognoses, the loss of functional capabilities, and the need for advanced care planning are just some of the emotionally charged challenges of caring for individuals with advanced illness.

Case Management for Advanced Illness: Best Practices in End-of-Life Care examines Aetna's Compassionate Care program, a case management approach for this population. The payor's initiative breaks down barriers commonly encountered in this highly sensitive stage of the health continuum while positively impacting both healthcare utilization and spend.

In this 30-page resource, Dr. Joseph Agostini, senior medical director, Aetna Medicare, shares the key features of the Compassionate Care Program at Aetna, along with the impact the program has had on healthcare utilization and quality outcomes.

He also answers a range of questions on the initiative, including the role of palliative care, strategies for educating and engaging both providers and patients in care management for advanced illness, transitioning patients to this stage of care management, and the ideal traits of the Compassionate Care case manager.

Additionally, Sheryl Riley, RN, OCN, CMCN, managing partner, Clarion LLC, draws upon her 10 years of experience in care and case management of oncology patients to share the case manager's perspective. In a Q&A interview, Riley, not associated with the Compassionate Care program, describes some of the challenges of the field, including the shifting definition of care management and an emerging trend in oncology care management, care of the survivors.

This resource provides details on the following:

• How providing information, tools and resources contributes to higher quality of care for those with advanced illness;
• Best practices and barriers that commonly arise during the care of advanced illness patients;
• Patient identification and engagement techniques, including the use of motivational interviewing to improve communication and goal attainment;
• How a member-centric system, which includes case management and other clinical assessments helps case managers address the holistic needs of the patients; and
• Results from the program that illustrate the program's impact at the best intersection of quality and cost.

Table of Contents

• A Case Study on Aetna's Compassionate Care Program
  • Defining Advanced Illness
  • Medicare Spectrum of Care
  • Decision to Pursue Palliative Care
  • Goals of Aetna Compassionate Care Program
  • 4 Ways to Identify Cases for Compassionate Care
  • Case Manager Responsibilities
  • 3 Barriers to Care Management of Advanced Illness
  • Educational Opportunities
  • Best Practices of Compassionate Care
  • Outcomes and Results
• The Case Manager Perspective: Survivorship Next Critical Challenge for Oncology Care Managers
• Q&A: Ask the Experts
  • Starting Point for Advanced Illness Care Coordination
  • Physician Engagement in Advanced Illness Care
  • Role of Palliative Care
  • Transitioning Patients to End-Of-Life Care
  • Patient Education in Compassionate Care
  • Change Management and the Case Manager
  • Program Engagement Rates
  • Physician Training Collaborative
  • Attributes of the Compassionate Care Case Manager
  • Covering Home-Based Services
  • Contracting with Community Care Providers
  • Case Manager-Patient Interactions
• Glossary
• For More Information
• About the Contributors