Available only through Sutter VNA & Hospice.
What about patients too sick for home care and not ready for hospice?
Some patients are not ready to abandon active treatment even in late-stage illness. To help care for those patients, Sutter VNA & Hospice has developed the Advanced Illness Management (AIM) program to provide home-based palliative care and "transition management" for patients with advanced chronic illness.
Our specially trained AIM home care 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 enrollment.
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What AIM Offers
Goals of AIM
AIM is Different From Home Health Care
AIM is Not Hospice
Admissions
Admission Criteria
Availability
Refer a Patient
For More Information
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What AIM Offers
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A full range of medical services at home for patients with serious illness.
Management of the transition from curative treatment toward end of life care.
A customized blend of disease-modifying and comfort care.
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Goals of AIM
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Provide care to patients who are within 6-12 months of end of life.
Discuss disease process and prognosis with patient, family, and physicians.
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 visits and hospitalizations.
Encourage earlier use of hospice.
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AIM is Different From Home Health Care
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(though it is based in home care)
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Home care promotes recovery and rehabilitation.
Home care is episodic: patients are admitted and discharged quickly.
AIM promotes transition toward end-of-life care for patients with end-stage illness.
AIM focuses on symptom management and comfort.
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AIM is Not Hospice
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(though it encourages hospice use)
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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.
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Admissions
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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 criteria below.
All patients (with the exception of hospice referrals - see below) referred to AIM must be home care eligible, meaning homebound with skilled nursing needs. (Medicare patients must meet "homebound" criteria. Some other insurers require patients to be homebound, others do not.)
Patients who qualify for hospice but refuse hospice enrollment are eligible for AIM.
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Admission Criteria
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AIM referrals should satisfy at least TWO of the following criteria:
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Diagnosis of cancer, advanced CHF, end-stage pulmonary disease, end-stage hepatic 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 effectivenes. i.e., Cancer: chemotherapy ineffective. CHF: refractory fluid overload. COPD: severe or frequent exacerbations. Neurological: recurrent stroke, dysphagia.
Decline in functional status and/or nutritional status in past 30 days.
Eligible for hospice, but refuses enrollment.
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Availability
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The AIM program is currently available in parts of Alameda, Contra Costa, San Mateo, and Sonoma Counties, and is expected to expand to additional Sutter VNA & Hospice service areas this year.
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Refer a Patient
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To find out if AIM is available in your community, or to refer a patient for AIM, please call 1-800-557-9777.
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For More Information
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Dr. Brad Stuart, Sutter VNA & Hospice Senior Medical Director, is available to discuss AIM, answer any questions you may have about the program, and for consultation about the appropriateness of the program for individual patients. Please contact Dr. Stuart at (510) 450-8533 or by
">e-mail.
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