Module C: Transdisciplinary Team Care

CE Credits: 1.5


This module explores how optimal and successful implementation and growth of a palliative care program requires transdisciplinary participation and support from:
» C-Suite
» Attending/referring physicians
» Palliative care specialists and team members
» Case managers
» Other front-line clinicians

Case managers are an integral part of the transdisciplinary team providing palliative and EOL care. Combining palliative care with the case management approach is a logical, feasible and effective strategy to improve the care of seriously ill patients.

Learning objectives: After completing this module the case manager will be able to:
» Discuss an organizational culture for success
» Define the team-led approach to palliative and EOL care
» Describe team-led care planning in palliative and EOL care
» Discuss palliative and EOL care teams
» Identify professional balance achievement and burnout avoidance
» Review case management credentials and standards

Advance your professional practice:: Case managers, palliative care clinicians and other team members must understand that they will be called upon to adopt new models that extrapolate their direct patient care skills to population management strategies including developing targeted, “triggered” interventions to enhance patient-centered, goal-consistent and coordinated care.


Improve organizational performance: Case managers need enhanced knowledge to achieve the overriding goal of developing a palliative care service that fulfills the needs of patients, families and clinicians and is designed to:
» Grow palliative care services
» Demonstrate the effect on costs and quality
» Engage physicians to overcome resistance
» Gain buy-in, and increase referrals
» Overcome capacity challenges by employing a generalist palliative care model