Some patients are simply not prepared to abandon active treatment even in late-stage illness. To help care for those patients, Health Alliance Home Health and Hospice has developed the Advanced Illness Management (AIM) program to provide home-based palliative care and “care-transition management” for patients with advanced chronic disease.
Our specially trained AIM home health and hospice nurses, social workers and other team members provide pain and symptom management, advance care planning, and end-of-life care to patients who are not yet ready for hospice, or have refused hospice election.
What Our AIM Program Offers
A full scope of medical services at home for patients with serious illness.
Management of the transition from a curative plan of care toward end of life care.
A specialized blend of disease-modifying and comfort care.
Goals of the AIM Program
Provide care to patients who are within 6-12 months of end of life.
Counsel patients and families on disease process and prognosis.
Provide physicians with consultation on home based palliative care and end of life care.
Decide on goals of treatment.
Establish realistic and effective plan of care.
Facilitate advance care planning.
Manage symptoms, especially pain and dyspnea.
Prevent unnecessary emergency department visits and hospitalizations.
Encourage earlier use of hospice through pre-hospice counseling.
AIM is a Specialized Home Care Program
Traditional home care promotes recovery and rehabilitation.
Traditional home care is short term and episodic: patients are admitted and discharged quickly.
AIM promotes transition toward end-of-life care for patients with late-stage illness.
AIM focuses on symptom management and comfort.
AIM is Not Hospice
(it does however promote hospice awareness)
Hospice is for the terminally ill.
Hospice patients must forego disease-modifying treatment.
Hospice provides aid in dying.
AIM is for patients with advanced illness who may not yet be “terminal.”
AIM is also for patients who are terminally ill but who have not yet chosen hospice.
AIM provides concurrent curative and comfort care.
The key question to ask yourself is: Would you be surprised if this patient died in 6-12 months? If the -answer is “NO,” evaluate the patient for AIM using the admission criteria below.
All patients (with the exception of hospice referrals) referred to AIM must be home care eligible, meaning homebound with skilled nursing needs. (Medicare patients must meet “homebound” criteria. Some commercial insurers require patients to be homebound, others do not. If you are not sure of the coverage criteria please call and we can provide you with this information)
Patients who qualify for hospice, but refuse hospice enrollment, are eligible for AIM.
AIM referrals should satisfy at least TWO of the following criteria:
Have a diagnosis of cancer, advanced cardiac disease, end-stage pulmonary disease, end-stage liver disease, end-stage neurological disease, other end-stage medical diagnosis, or advanced debility and decline.
Non-palliative treatment of primary disease process is failing or losing effectiveness.( i.e., Cancer: chemotherapy ineffective. CHF: refractory fluid overload. COPD: severe or frequent exacerbations. Neurological: recurrent stroke, dysphagia.)
Patient has poorly controlled pain, dyspnea, or other end of life symptoms.
Decline in functional status and/or nutritional status in past 30 days.
Eligible for hospice, but refuses enrollment.
Refer a Patient or For More Information
To refer a patient or receive more information about the HealthAlliance Home Health AIM program, please call (978) 728-0621