BRONSON AT HOME

ADVANCED ILLNESS
MANAGEMENT
PROGRAM
April 22, 2015

Tina Shivley, Leisa Butts, Candace Graham, Janet

Hoffman, Linda Rowse

Advanced Illness
What is Advanced Illness?
The Coalition to Transform Advanced Care defines
advanced illness: One or more conditions serious enough that
general health and functioning decline and treatments begin to
lose their impact.

Why Advanced Illness Management?

Even though the trajectory of advanced illness leads to
death, many studies show that well developed AIM programs
improve quality of life, lower utilization of clinical treatments,
decrease hospital re-admissions, increase patient and family
satisfaction and reduce aggregate spending.
Coalition to Transform Advanced Care (CTAC) 2011

Four Components of AIM

Advance Directives, Advance Care Planning,
Palliative Care, and Hospice
are the four components of successful
Advanced Illness Management initiatives.
Goals:
Facilitate advance care planning for patients
and families facing chronic illness
Avoid unnecessary hospitalization
Improve symptom management and quality
of life

AIM POSSIBLE DISCHARGE TRANSITIONS

Community Palliative Care (AIM)

Pending
Home Health Care (AIM Program)
SNF
Select Specialty Hospital
Home
Hospice/Hospice Residence

Bronson at Home Model

Interim program provided by Bronson at Home until the
system Bronson Advanced Illness Management (AIM) program
is available in Calhoun County.
Use of the Advanced Illness Management name to avoid
consumer confusion.
Advance Care Planning providing a process of communication and
care coordination between the hospital and Bronson at Home by
utilizing a Bronson at Home social worker to assist identified AIM
patients at the Hospital.
Bronson at Home AIM program is NOT an AIM Community Model
Program it is a program developed under the Bronson at Home
Healthcare services line.

Bronson at Home AIM Program Details

The Bronson at Home AIM will be provided in the

Certified Healthcare service line.
It will serve as a Bridge between Hospice and
Healthcare services.
Hospice nurses, social workers, home health
aides and chaplain will be trained to Healthcare
services regulations, processes and EPIC as the
program functions under the Healthcare services
guidelines.

Bronson at Home AIM Program Criteria

Must meet homebound criteria: requires
considerable and taxing effort to leave home
Diagnosis of advanced life-limiting illness such as:
cancer, advanced CHF, end-stage pulmonary
(COPD) or neurological disease, advanced dementia
Treatment of primary disease process is failing or
losing effectiveness, such as:

Cancer: ineffective chemotherapy

CHF: refractory fluid overload
COPD: severe or frequent exacerbations
Neurological: recurrent stroke, dysphagia
Pneumonia: repeated hospitalizations

Bronson at Home AIM Program Criteria

Decline in functional status OR nutritional status

in the past 30 days
Uncontrolled pain or shortness of breath, or other
symptoms severe enough to limit activity
Has a deteriorating medical condition and is at
risk for needing symptom management. May
have had 1-2 ER or hospital admissions in the last
year.

Bronson at Home AIM Program Detail

Process
CONNECT/Case Management identifies potential AIM
patient and make referral to Hospital Palliative Care
Palliative Care sees the patient within 2-3 days and if
patient is not ready for hospice, but is appropriate for AIM,
makes a referral to Bronson at Home Hospice Social
Worker for a consult (Advance Care Planning).
Bronson at Home Social Worker to visit the patient in the
hospital, discuss patient goals and objectives, review
advance directives if needed, make recommendation for
discharge:

Advanced Illness Management Program at Bronson at Home

Hospice
Healthcare Services
Unknown (not skillable and/or not homebound)
Other

Bronson at Home AIM Program Detail

Process Continued
If AIM is appropriate and criteria met, referral is made to
Bronson at Home Healthcare Services for the AIM Program
AIM/Hospice nurse makes contact with the patient and
following physician to explain AIM program goals and
mission
Start of Care is completed by Healthcare Services and Case
Management AIM/Hospice Nurse is assigned
AIM/Hospice nurse and Healthcare Services nurse work
together to determine visit frequency, and additional
disciplines (social work, nursing, PT/OT, home health aides,
chaplain).
AIM/social worker visits are heavily loaded to assist the
patient with psycho-social issues regarding AIM and possible
transfer to Hospice.

Bronson at Home AIM Program Detail

Process Continued

AIM program finishes at the completion of the

Healthcare episode.
AIM/Case Manager discharges patient to:
Hospice
Home with follow-up calls by social worker at day 3,
7, and 14
Home no follow-up if patient refuses

BARRIERS
Time to train all Hospice nurses, social workers, home
health aides and chaplain to Healthcare services
regulations and processes (ie. orders for medications,
etc.) Unit Coordinators able to complete this training
following EPIC training.
Time to train all Hospice nurses, social workers, home
health aides and chaplain to EPIC. This would be 18+
hours of classroom training for approximately 13 staff.
Darinda Blaskie is currently working with IT to make
the arrangements for this training.
Staffing coverage while training occurs.
Lap top computers for Hospice nurses, social workers
and chaplain

BARRIERS
If identified AIM patient is not homebound
or does not have a skilled need the AIM
program wouldnt be able to meet their
needs
Identified AIM patient agrees to Hospice
but does not meet the Hospice
requirements for admission.
Need to consider after hours coverage
for all disciplines to meet the AIM patient
need

Bronson at Home AIM Program Goals

Improve symptom management and quality of
life
Avoid unnecessary hospitalization and emergency
room care
Provide the opportunity for the patient to self
reflect what they want and hope for
Facilitate discussions with the patient about
alternative options
Provide guidance with Advance Directives
Create an opportunity for Advance Care Planning
using a Hospice Social Worker in the Hospital

Thank you!

bronsonhealth.com