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Advanced Illness Management Program

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by

Michael Raphelson

on 26 November 2013

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Transcript of Advanced Illness Management Program

ADVANCED ILLNESS MANAGEMENT
Current Resources
Pick a model/structure
System-wide workgroup
Operationalize and Market
History
2002 - 2004 Joint venture Pilot PC program
with HCSWM, NP and physician(s)

Palliative Care team at BMH
PC Nurse at BBC
Advanced Illness Management Program
Inpatient Palliative Care Service

Clinical/administrative
NP
MSW
Chaplain
55 - 80 consults/month
Adult/Peds/NICU
High utilization/respected
Institutional support
JCAHO Accreditation elligible
HCSWM
30 + years delivering community
based home care
Palliative care Physicians
Schedulers
Home visit Program evaluation Team
Billing infrastructure
Hospice services
24 nursing services and on-call
Desire to provide adv. illness managment services
Need for AIM option for
current referrals
Need for earlier hospice
referrals

Subcommitee Workgroup on Palliative Care
Recommendations:

Work To DO!


BMH & BBC AIM Inpatient teams- equal care & service
Transition Coaches to bridge inpatient and outpatient
services for AIM patients from BMH, BBC, BLH.
Community-based outpatient multidisciplinary team in the
home/coordinated with PCPs. A community
collaboration with HCSWM / Bronson.
Bronson Commons
Hospice care



Bronson System Future Model

1. Adopt the term “Advance Illness Management” in
lieu of palliative care.

2. Hire or contract physician champion certified in a
palliative medicine as Medical Director to
champion this effort and provide patient care

3. Identify physicians not certified in palliative
medicine to receive additional training in PM

Recommendations (18)

4. Develop a Bronson system infrastructure to
oversee and direct the implementation &
integration of Advance Illness Management.

5. Adopt best practice clinical care guidelines for
AIM across the system. Include advance care
planning for potential ED visits.

6. Integrate access to Ethics Committee for
assistance with complex cases.

7. Standardize staff education and training in AIM.

8. Identify/develop communication venues so that
community and transition patient care
plan/notes can be viewed by the whole health
care team, including community partners.

Recommendations

9. Adopt a system-wide Advance Directive form
readily available electronically.

10. Develop system-wide resources for Advance
Illness Management easily accessible by staff,
patients, families and providers.



12. Establish a Pediatric medical home for patients with advance illness to ensure coordination
of services and care and to maximize Medicaid reimbursement.

13. Develop a pediatric AIM team to meet with patients, their families & the community supports to
provide education on the different stages of advance illness management.

16. Determine a financially sustainable model for
inpatient and outpatient Advance Illness Management.

Professional billing
Cost avoidance
Reduced avoidable re-hospitalizations
In-kind cost sharing with community partners.
Medicaid reimbursement (peds.)

Recommendations


17. Bronson will participate in a community
awareness campaign with other community
leaders to raise awareness and
acceptance of advance directives.

18. As AIM develops and is integrated,
Bronson will align with insurers
for additional incentives.

Recommendations

1. Identify System Transitions Director
2. Hire physician champion, certified in PM
3. Complete a financial proforma to determine
impact on the system & each Bronson entity.
4. Focus groups- Consumers
5. Initiate discussions on financial and operational
model for HCSWM/ Bronson collaboration on an
Outpatient AIM Team.

Next Steps

11. Develop an Outpatient AIM team, that is community based, provides services in home coordinates with PCPs

Outpatient AIM team in collaboration with HCSWM/Bronson will be multidisciplinary for both adults and pediatric patients/families

Taking referrals for Phase 3 complex patients for extended lengths of time, indefinitely, till transition to hospice care or death.

Recommendations to Executive Committee Bronson Healthcare Group
2002 Opened AMU as a ACE Unit
Recommended Model from Workgroup
Division of Palliative Care Services

Inpatient PC Teams
NP,MSW, Chaplain

Outpatient AIM team
NP,MSW,Chaplain,Volunteers,
(others as needed from Hospice IDT)

Medical Director/Consultant

Team members cross between inpt/outpatient for continuity with patients and families.

Cross coverage from team members
24 hour call coverage
Physician available for consults as ne
eded
Reach out to:
Medical Staff/Specialty Community
Primary care/Community providers
LTC/ALF/Medical Facilities

Physical Space
Administrative Structure
Develop Best Practice Tools
Improve symptom management and quality of life
Clarify patient values and goals of care for patients and families
Avoid unnecessary ER/Hospital visits through coordination of care and
medical management
Decrease unnecessary/unwanted care in the last 6 months of life
Decrease in-hospital mortality

GOALS:
Target Population:
Phase 3 patients
Newly diagnosed incurable disease
Palliative Care Proven Outcomes:
Less hospital days
Less ER visits
Increased QOL
Increased patient/family satisfaction
Increased symptom control
Decreased rehospitalization admits
Decreased cost of inpatient care
Decreased cost of care for adv. Cancer patients
Full transcript