Advanced Illness Management Program (AIM)

Working with patients and their families in the end stages of advanced disease(s) that are not physically, emotionally, or spiritually ready for Hospice care.

Admission Criteria

Meet conditions for Home Health
Patients must be HOMEBOUND
Services provided by and under care of physician
Has intermittent skilled need
Must agree to scheduled LMSW within 72 hours of admission to AIM
Patient still desires to seek treatment for advancing illness
Patient likely to pass away in 6-12 months

Goals of AIM

To capture patients in the beginning of end stage of life
Advanced care planning to provide a transition from curative to comfort care
To effectively manage symptoms and pain
Work closely with members of a collaborative team, including the patient's physician, to create a plan that tailors to patient-specific goals
To encourage earlier and appropriate use of Hospice
To address Advance Directive within 1 week, no later than 30 days
To address Out of Hospital DNR within 30 days
To meet spiritual, cultural and emotional needs to patient with advanced illness

AIM patients can be referred to Doctor’s Choice from the community, a facility, a physician, or be an existing Agency patient. AIM patients will be serviced under our skilled home health service line with an emphasis on advanced care planning.

The AIM program brings Home Health and Hospice together to utilize the strength of each discipline in achieving a common goal; a focused, multidisciplinary approach to symptom and pain management.

Qualifying diagnosis for palliative care include:

Heart Failure
Enfermedad pulmonar obstructiva crónica
Cancer
Dementia
Parkinson's Disease
Renal/ESRD

ADVANCED ILLNESS MANAGEMENT (AIM) PROGRAM

Admission Criteria

Goals of AIM