Certificate Program in Integrated Care Management

Curriculum

(Each module is one hour in length, delivered two at a session over ten sessions.)

Care Management in the Patient Centered Medical/Healthcare Home

LEARNING OBJECTIVES:

  • Describe the role of care management in the PCMH
  • Describe the common medical and behavioral health needs of people with chronic illness

Team Approaches to Care: What We Need to Know to Work Together

LEARNING OBJECTIVES:

  • Describe ways to foster effective communication between the patient and all members of the care team
  • Describe ways to address communication challenges (such as language barriers, varied communication styles and role clarity confusion) among team members

Uunderstanding the Experience of Patients in the Healthcare Home

LEARNING OBJECTIVES:

  • List the most common barriers that the health system presents
  • Use positive relationships to improve the patients' experience with the team as a whole

Fostering Patient Activation Through Shared Decision Making and Goal Setting

LEARNING OBJECTIVES:

  • Describe the steps that help the patient take the advice-giving role
  • Develop and help patients complete a patient centered care plan

Networking in the Medical Neighborhood: Extending Care Management Beyond the Health Center

LEARNING OBJECTIVES:

  • List ways to identify high risk patients
  • List considerations for developing and using registries
  • Describe specific ways to facilitate collaborative care with external resources
  • Create a standardized and effective method to identify and track relevant referral information for community resources

Working with Geriatric Patients and Their Families

LEARNING OBJECTIVES:

  • Describe the unique health and behavioral health needs of a geriatric population
  • Describe evidence-based interventions for geriatric populations

Smoking Cessation, What a Care Manager Can Do

LEARNING OBJECTIVES:

  • List the stages of behavioral change and use it to inform how you discuss smoking cessation with patients
  • Educate and engage patients in the use of pharmacotherapy and behavioral interventions to quit smoking

Evidence Based Protocols FOR Depression Care Management

LEARNING OBJECTIVES:

  • Design and implement a screening protocol, including recommendations for appropriate level of care for depression
  • Describe evidence-based, longitudinal care management protocols for treatment of depression

Heart Disease 101

LEARNING OBJECTIVES:

  • Describe the pathology and impact of different types of heart disease
  • Describe at least 3 behavioral interventions for heart disease

AN INTRODUCTION TO MOTIVATIONAL INTERVIEWING SKILLS FOR CARE MANAGERS

LEARNING OBJECTIVES:

  • Name and utilize the four processes of MI (engaging, focusing, evoking, planning) to support patients effort
  • List the 4 primary MI skills and describe how to use them when working with patients who feel ambivalent

Diabetes Care: What Everyone Needs to Know

LEARNING OBJECTIVES:

  • Describe diabetes self care recommendations in ways patients can understand
  • List behavioral factors that affect health outcomes in people with diabetes

Controlling Weight and Supporting Exercise for Healthy Living

LEARNING OBJECTIVES:

  • Educate patients about simple lifestyle changes that can promote healthy weight loss
  • Identify and address barriers to increased activity and healthy eating

Care Management for Children and Their Families

LEARNING OBJECTIVES:

  • List pediatric health conditions with behavioral health concerns
  • Teach behavior modification techniques

Trauma Informed Care

LEARNING OBJECTIVES:

  • List empirically supported assessments and interventions for trauma
  • Provide basic education to patients and staff on the association between PTSD and health problems

Crisis Intervention

LEARNING OBJECTIVES:

  • Execute steps to take in an urgent situation, including accessing resources
  • Assess and respond to crises including suicidality, homicidal threats and fears of imminent harm in abusive relationships

Successfully Caring for Patients with Serious and Persistent Mental Illness

LEARNING OBJECTIVES:

  • Educate providers (PCPs, nurses, staff) about working with patients who have serious mental illness
  • Advocate for an facilitate access to healthcare for patients with SMI

Caring for the Homeless in Primary Care

LEARNING OBJECTIVES:

  • Describe approaches to facilitating self-efficacy and engagement in this population
  • List the barriers to Care Management for homeless populations and ways to address these barriers

Working with Unhealthy Substance Use

LEARNING OBJECTIVES:

  • Describe and educate providers on unhealthy substance use as a chronic illness
  • List and use conversational and form based screens for unhealthy substance use as a chronic illness

Understanding and Helping People with Chronic Pain

LEARNING OBJECTIVES:

  • Describe the relationship between stress and pain in approachable ways to patients and providers
  • Describe and list brief interventions, including behavioral cognitive and relaxation approaches, to improve pain coping